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Full text of "War neuroses and shell shock"

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WAR NEUROSES AND 
SHELL SHOCK 



PUBLISHED BY THE JOINT COMMITTEE OF 

HI'.XkY FROWDE AND HODDER & STOUGHTON 

1 WARWICK SQUARE, LONDON, E.C. 4. 



WAR NEUROSES AND 
SHELL SHOCK 



M.D., LL.D., F.R.S., F.R.C.P. ; BREVET LT.-COL. R.A.M.C. (T.) 

SENIOR NEUROLOGIST TO THE MAUDSLEY NEUROLOGICAL CLEARING HOSPITAL; 
CONSULTING PHYSICUN CHARING CROSS HOSPITAL; DIRECTOR OP THE PATHO- 
LOGICAL LABORATORY OP THE L.C.C. ASYLUMS; CORRESPONDING MEMBER OP 
THE NEUROLOGICAL AND PSYCHIATRICAL SOCIETIES OF PARIS 



WITH PREFACE BY 

THE RT. HON. CHRISTOPHER ADDISON, M.P. 

MINISTER OP RECONSTRUCTION 



LONDON 
HENRY FROWDE HODDER & STOUGHTON 

Oxford University Press Warwick Square, E.G. 

1919 



fniNTFD 1010 IN nnKAT britun hy k. n.AV ant> sons, lti>., 

BUt'NSWI. K 8TRBET, fiTAMKORD SIKKKf, 8.B. 1, AND BUNtlAY, 81'KKOl.K. 



DEC 7 2001 



TO 

A GROUP OF 
AMERICAN MEDICAL OFFICERS 

WHO WORKED WITH ME AT THE MAUDSLEY HOSPITAL 

THIS LITTLE BOOK IS DEDICATED 

AS A FRIENDLY MARK OF APPRECIATION OF 

THEIR EARNESTNESS AND EFFICIENCY 

IN THE STUDY AND TREATMENT OF CASES OF WAR 

NEUROSIS ADMITTED UNDER MY CARE 






^^3^ 



PREFACE 

By the Rt. Hon. CHRISTOPHER ADDISON, M.D., M.P. 

MINISTER OF RECONSTRUCTION 

My friend Brevet Lieut.-Col. F. W. Mott, F.R.S., has 
given me the privilege of saying a few words of intro- 
duction to his valuable book on War Neuroses and Shell 
Shock. Its importance will be obvious to all members 
of the medical profession, for the problems with which it 
deals will, unhappily, remain with us long after the end of 
the War. But it seems to me well to emphasise the fact 
that the book is above all a record of astonishing success 
in the treatment of disorders which at first sight, and to 
all laymen who encounter them as relatives or friends of 
the sufferers, must appear peculiarly painful, mysterious, 
and intractable. 

Since the outbreak of War the author has devoted his 
whole time to the investigation and treatment of cases of 
War Neurosis and Shell Shock, first at the Neurological 
Section of the 4th London General Hospital and later 
at the Maudsley Neurological Clearing Hospital. He has 
therefore had unusual opportunities of studying the subject, 
and this work is based mainly upon his own experience, 
although foreign literature is quoted freely, especially the 
important work of the French Neurologists. 

The book brings together the conclusions which he has 
derived not only from extensive clinical observations, but 



viii - PREFACE 

also from much original anatomical research relating to 
the effects of Shell Shock and Gas Poisoning upon the 
central nervous system. A good deal of this work has 
been published in the Lettsomian Lectures of the Medical 
Society, The Effects of High Explosives upon the Central 
Nervous System, 1916, as well as in other addresses and 
communications to learned Societies. 

It is, I believe, the only complete account yet published 
of the pathological changes in the nervous system in Shell 
Shock and Gas Poisoning. It is in these changes that 
an explanation must be sought of the symptoms met 
with in fatal cases of Shell Shock and concussion of the 
brain and spinal cord, so that Col. Mott's researches should 
be instructive and interesting to the medical profession 
from a practical as well as from a scientific point of 
view. 

As Pathologist to the L.C.C. Asylums, Col. Mott was 
able to turn to account his pre-war studies on hereditary 
predisposition by pointing out early in the War the import- 
ance of the inborn-factor in the production of War Neuroses 
and Psychoses, and he emphasises in this work the futility 
of trying to make good soldiers out of poor material. A 
conscript army drawn from all grades of society, after a 
medical examination which can hardly be expected as a 
rule to be of a specialist standard as to fitness for general 
service, will in his view of necessity contain a large percent- 
age of men with an inborn or acquired nervous predis- 
position, who when put to the severe nervous strain of 
shell fire and the stress of trench- warfare break down 
after a short time, either from exhaustion or from emotional 
shock. 

Col. Mott is concerned to show that the majority of 
cases of so-called " Shell Shock " are truly " Emotional 
Shock." He illustrates his argument by comparative 
statistics. It has been calculated that one-seventh of all 
the soldiers who have been discharged from the army as 



PREFACE ix 

permanently unfit, or one-third of the unwounded, are 
cases of Shell Shock, War Neurosis or Psychosis. It would 
be difficult to exaggerate the gravity of this statement. 

Another set of statistics upon which Col. Mott lays 
stress is the large number of higher-grade mental defectives 
discovered in the course of the medical examination of the 
male population of military age. As the Prime Minister 
has said, we have discovered that thg?e are too many C3 
men, and it will be the endeavour of all concerned with 
health administration to make an increase in the numbers 
of Al men part of the programme of Reconstruction. 

Col. Mott points out that the War Neuroses present no 
essential clinical differences from those met with in pre- 
war days. They belong to the two great groups of func- 
tional nervous diseases — hysteria and neurasthenia — the 
symptoms being the same, but coloured by war experi- 
ences. Numbers of illustrations are given which show 
that the psycho-pathology of war " consists fundamentally 
in the exaggeration and perseveration of instinctive defence 
reactions incidental to normal physiological conditions, viz. 
protective pain, fatigue, and the emotion of fear." 

The Psychology of Soldiers' Dreams is of great interest, 
for it shows how true is the statement of Lucretius : 
" And generally to whatever a man is closely tied down and 
strongly attached, on whatever subject we have previously 
much dwelt, the mind having been put to a more than 
usual strain in it during sleep we for the most part fancy 
we are engaged in it." 

A large number of striking photographs of patients, 
before and after treatment of their disabilities and de- 
formities, illustrate the work. One statement which the 
author makes seems to me to be of peculiar interest as 
indicating that the treatment of functional motor dis- 
abilities and deformities urgently requires increased atten- 
tion, with a view to the saving of health and happiness 
in the interests alike of the sufferers from these disorders 



X PREFACE 

and of the community. It is that large numbers of eases 
of functional disabilities and deformities in the nature of 
paralysis and contractures, whether associated with wounds 
or not, have been cured by him in a few minutes, a 
few hours, a few days, or at most a few weeks, even 
though they had existed many months and sometimes a 
year. 

Inasmuch as largp numbers of these cases have been 
discharged from the Services uncured, and are receiving 
pensions, it follows that the subject of " War Neuroses 
and Shell Shock," though the War is now over, will be one 
of immediate national importance to the Ministry of 
Pensions, and to the projected Ministry of Health, and 
must remain so for years to come; for the longer these 
disabilities are allowed to persist the more difficult are they 
to cure. A book, therefore, which deals comprehensively 
with this subject cannot fail to prove of great value. 

Col. Mott develops the argument that fear is a biological 
instinct, and emphasises the enormous importance of con- 
templative fear in the perseveration of hysterical paralysis, 
contractures, and speech defects. Now that hostilities 
have ceased, and the idea of return to an intolerable 
situation has been removed, large numbers of these cases 
should spontaneously recover. 

Still, a large number of discharged men suffering from 
functional disabilities are in receipt of pensions, and Col. 
Mott takes the view that the receipt of a pension suggests 
permanence of the disability. It is, he points out, a well- 
established fact that the effective mode of cure of hysterical 
manifestations is contra-suggestion, and he concludes that 
every effort should be made to induce such men to take 
up suitable employment, and that no man should be 
discharged with a curable functional disability and 
without the prospect of employment. In the Chapter on 
Treatment attention is called to the value of occupation 
as a mental diversion, and graduated employment on the 



PREFACE xi 

land and in the workshop is strongly advocated as a means 
of promoting convalescence. The importance of estab- 
lishing an atmosphere of cure in a hospital is emphasised, 
and music, including training in singing, is strongly recom- 
mended as a means of restoring health to mind and 
body. 

C. Addison. 



CONTENTS 



The effects of high explosives upon the central nervous system 

A brief survey of the dynamic conditions of the central nervous 
system, especially in relation to the cerebro -spinal fluid and shock 

The neuron doctrine in relation to " shock " and the theory of 
diaschisis ..... 

The living neuron in relation to shock . 

Oxygen and consciousness . . 

Physical shock and psychic shock 

Different forms of shock. Theories of causation 

The nature of high explosives and forms of projectiles 

Theories regarding causation of instantaneous death of groups of men 

General description of the signs and symptoms of commotional shock 

Description of a common type of commotional case 

Description of severe emotional shock following commotion 

Consecutive phenomena of shock . . . . 

Summary of liistological changes .... 

Spinal concussion ...... 

Microscopic examination of portions of tlie spinal cord 

Opinions of French and German neurologists regarding shell shock 
by windage .... 

Experiments vipon animals . 

The effects of windage (vent du projectile) upon the eye 

The ear ....... 

Voltaic vertigo ...... 

Mental confusion with hallucinatory delirium 

Mental confusion and hebetude 

Shock in relation to loss of memory 

Memory and recollection .... 

Periodic amnesia ..... 

Musical memory in relation to shell shock 

Hysterical speech defects .... 

Pathogenesis of mutism .... 

The predisposing factors of war psycho-neuroses 

xiii 



and 



PAGK 

1 



6 
S 
16 
16 
16 
23 
24 
29 
31 
33 
36 
38 
54 
63 

67 
70 
71 
74 
76 
79 
80 
84 
86 
89 
91 
94 
102 
107 



XIV 



CONTENTS 



Comparative study of the personal history of 100 cases of war 
psycho-neuroses and 100 cases of wounded 

Psycho -neuroses in recruits and conscripts .... 

The psychology of " soldiers' dreams " in relation to neurasthenia 

Soldiers' dreams and the doctrine of Freud .... 

Dreams in relation to the unconscious ..... 

Dreams in relation to neurasthenia of soldiers 

Emotional and commotional shock in relation to soldiers' dreams 

Secreto-motor and vaso-motor reactions the outcome of suppressed 
fear during the waking state . 

Secreto-motor and vaso-motor reactions the outcome of terrfyin 
dreams ....... 

Effects of the dream the next day 

War psycho -neuroses • . . . . . 

Psychogenic motor disorders and disabilities . 

The mental conflict in relation to war psycho-neuroses 

Hysterical paralyses and contractures . 

Hysteric monoplegias and paraplegia 

Contractures of the trunk ..... 

Functional paralysis or contracture of a circumscribed regif)n of the 
hands, the feet, the shoulder, the trunk and the neck 

Disorders and disabilities of gait and station . 

Tremors, tics, and choreiform movements 

The diagnosis of liysterical paralyses and contractures 

Differential diagnosis of peripheral neuritis and hysterical paralysis 

Late tetanus and reflex contracture 

Diagnosis of functional and organic disease 

The diagnosis of contractures and paralysis of limbs following 
injuries and wounds ..... 

Examination of patient ..... 

Psychopathic sensory disturbances and disabilities 

The psychopathic sensory disabilities . 

The anaesthesias, analgesias, hypersesthesias . 

Loss of bone sensibility and of the kinsesthetic sense 

Reflex reaction in relation to hysteria and malingering 

Psycho -sensorial affect 

Deafness . 

Vision 

Sphincter affections 

Neurasthenic signs and symptoms 

Course and progress of the psycho-neurosc!' 

The psychoses of war .... 

The psyohoses ..... 



CONTENTS 

Exhaustion psychosis 

Dementia prsecox 

Psychasthenia 

Feeblemin dedn ess 

Epilepsy . 

Differential diagnosis of idiopathic epilepsy and traumatic epilepsy 

Differential diagnosis of epilepsy and hystero-epilepsy 

Masked epilepsy . . . 

Manic depressive insanity ..... 

Paranoia — acute and chronic delusional insanity 

Disposal of mental cases ..... 

GeAeral paralysis and other organic brain diseases . 

The diagnosis of malingering .... 

Behaviour when under examination 

The exclusion of organic or functional disease 

Alcohol and war neuroses ..... 

Alcohol as a food ...... 

Carbon monoxide gas poisoning .... 

Pre-war knowledge of the pathology of CO gas poisoning 

Illuminating gas 

Pathology of CO poisoning 

Miliary haemorrhages in cases of shell concussion and gas poisoning . 

Anatomical relations of the vessels favouring capillary stasis and 
haemorrhage ......... 

Shell shock and burial. CO poisoning . ..... 

Examination of the brain in gas poisoning ..... 

Brief clinico -anatomical notes of this case ..... 

Microscopic examination of the brain in shell concussion with gas 

poisoning .......... 

Examination of a brain from a case of gas-shell poisoning 
Siunmary ........... 

Gas burning in mines and from imperfect detonation or burning of 

explosives in the operations of war . . . , . 

Causes of explosives producing poisonous gases .... 

How CO poisoning cases are caused ...... 

Symptoms of CO poisoning ........ 

After-effects of CO poisoning ....... 

Prevention of gas poisoning and accidents in mines 

Treatment .......... 

The effects of irritant gases upon the brain . . 

Neurasthenia and active service ....... 

Chronic functional paralysis and contractures in pensioners 



XV 

PAGE 

203 
205 
206 
207 
208 
209 
210 
212 
213 
214 
214 
215 
217 
218 
220 
222 
225 
228 
229 
231 
232 
236 

237 
238 
240 
244 

245 
246 
247 

249 
250 
251 
253 
255 
257 
258 
259 
260 
263 



XVI 



CONTENTS 



The general treatment of war psycho-neuroses 

Treatment of shell shock and neurasthenia 

Mental hygiene in later stages 

Treatment of hysterical paralyses, contracture, mutism and other 
disabilities ...... 

The atmosphere of cure . . . . 

Exercises for convalescent cases of war neurosis 

Treatment of hysterical sensory conditions 

Physio-psychotherapy in the treatment of mutism 

Treatment of stammering and stuttering 

Physio-psychotherapy in the treatment of paralysis and analgesia 

Freud's theory of the unconscious in relation to the treatment o 
war psycho-neuroses by psythj-analysis . ... 

Psycho-analysis by word association ..... 

The galvano-psychic method of investigation 

The reaction of the neurasthenic and hysteric contrasted 

Test of memory and responsibility in officers suffering with 
neurasthenia 

The gymnasium 
contractures 



in treatment after functional paralysis and 



After-treatment by occupation 
Bibliography 



PAOU 

267 
268 
270 

272 
275 
280 
281 
282 
283 
286 

287 
287 
288 
291 

292 

295 
29(> 
298 



APPENDIX 

Introduction 

Method of examination 

Examination of patient 

Motor function . 

Investigation of sensibility 

Reflexes 

Electro-diagnosis 

The Condenser . 

A scheme for clinical examination ot a ik rvmis ca^ 

Index ... .... 



:jo2 

;K)3 
305 
306 
307 
316 
317 
323 
324 

329 



LIST OF ILLUSTRATIONS 
COLOUR PLATES 

PLATK Facing page 

I. Section of optic thalamus, from a case of phosgene gas-poisoning, 
showing vessel blocked with pigment going to haemorrhage; 
amidst the blood corpuscles are numerous pigment granules. 
To the left of the larger vessel are three capillaries packed 
with pigment and compressed together ( x 350) . . . 242 

II. Small vessels blocked with pigment in haemorrhage, and to the 
right a larger vessel, probably a vein, filled with lightly brown- 
stained hyaline thrombus ( X 150) ...... 244 

III. Section of frontal cortex from case of shell-gas poisoning. Hya- 
line thrombus of vessel in the centre of haemorrhage (X 150) . 246 

FIGURES IN THE TEXT 

Fia. V\QE 

1. Diaschisis .......... 

2. Diaschisis .......... 8 

.3. Five cells from a case of a man who lived eight hours after 

receiving an electric shock of 20,000 volts .... 9 

4. Anterior horn cell of spinal cord examined immediately after 

death by direct illumination . . . . . .11 

5. Drawing of a living anterior horn cell examined by dark-ground 

illumination . . . . . . . . .12 

6. Haemorrhage into the sheath of a vessel in the median raphe of 

the medulla in a case of shell shock ..... 39 

7. An arteriole breaking up into capillaries with dilated perivascular 

space in shell shock . ' . . . . . . .39 

8. Section of cortex with collapsed and empty arteriole . . 40 

9. A small vessel cut longitudinally in the internal capsule with 

haemorrhage into sheath ....... 40 

10. Haemorrhages into the white matter of the pons . . . 41 

11. Cells of the vago-accessorius nucleus at the level of the calamus 

scriptorius — case of shell shock ...... 43 

12. Cells of the adjacent hypoglossal nucleus . . . .43 

13. Section of cerebellum ........ 44 

14. Betz cells of leg area ........ 44 

15. Section through the whole brain — shell shock . . . .50 

16. Vertical section through the left hemisphere in the frontal region 60 

xvii 



xviii LIST OF ILLUSTRATIONS 

PIG. 

17. Vertical section through hemisphere 

18. Photomicrograph of section of corpus callosimi 

19. Section of medulla oblongata 

20. Photomicrograph of a Betz cell 

21. Section of the fifth cervical section of spinal cord — shell-shock 
concussion ..... 

22. Section of the fourth cervical segment 

23. Section of the third cervical segment 

24. Longitudinal section of periphery of posterior column 

25. Section of third cervical segment of spinal cord case of concussion 

26. Section of periphery of posterior column . ' . 

27. Myelinated projection fibres in the motor cortex 

28. Medium-sized anterior horn cells in first lumbar segment 

29. Haemorrhage at the base of the posterior horn . 

30. Two liEirge anterior comual cells from the third lumbar segment 

31. Patient sufTering fronn shell shock : first period 

32. ,, • „ ,, second period 

33. ,, ,, ,, third period 

34. Diagram to illustrate the twofold mechanism of articulate speech 
36. Hysterical paralysis — condition of right arm before treatment 

36. Condition of right arm after treatment 

37. Functional facial paralysis 

38a. Photograph showing complete immobility of left arm 
38b. Case of brachial monoplegia 
38o. Ctise of brtichial monoplegia after treatment 

39. Functional hemiplegia .... 

40. Functional brachial monoplegia 

41. Functional right brachial monoplegia 
Functional contracture .... 
Long-standing functional paraplegia 
Functional spastic paraplegia 
Functional curvature of spine 
Accoucheur hand . 
Functional paralysis of hand 



42 
43 
44 
46 
46 
47, 

48. Functional main en griff e 

49. Functional paralysis of hand 

60. Ataxic astasia-abasia 

61. Blepharospasm 
52. Functional facial spasm and torticollis 

63. Ulnar paralysis .... 

64. Median nerve paralysis with acro-cyanosis of insensitive area 
55. Acro-cyanosis of neurasthenia ..... 



LIST OF ILLUSTRATIONS xix 

Flo. PAGE 

56. Right hemisphere of a worker at the nickel carbonyl manufactory 232 

57. Vertical sections through the hemispheres .... 233 

58. Section of corpus callosum ....... 234 

59. Vertical section of cerebral hemisphere of woman who committed 

suicide by illuminating gas ...... 235 

60. Section of corpus callosum ....... 238 

61. Punctate haemorrhages in corpus callosum . . . .241 

62. Hyaline thrombus of vessel in centre of punctate haemorrhage . 242 

63. Leash of small perforating opto-striate arteries filled with pigment 

granules .......... 243 

64. Small vessel breaking up into a leash of small arterioles . . 244 

65. Three punctate haemorrhages ...... 245 

66 Sections of medulla oblongata ...... 254 

67, 68, 69. Penetrating bullet wound of arm, with functional paralysis 

cured by suggestion ........ 264 

70. Injury of median nerve ....... 265 

71. Accoucheur hand under chloroform an.Tsthesia . . . 266 

72. Footprints of feet with functional contracture .... 272 

73. Photograph of the same feet showing well-marked inversion 

with extension of toes and ankle ..... 273 

74. Cured by contra-suggestion treatment ..... 273 

75. The room of recovery ........ 276 

76. Footprints 278 

77. Footprints 279 

78. Ergograph tracings of normal, hysteric and neurasthenic cases • 293 

APPENDIX 

Peripheral sensory nerve disiribviion of the upprr and 
lower limbs (after Beniaty) 

1. Peripheral sensory distribution of the upper extremity (palmar 

aspect) 310 

2. Peripheral sensory distribution of the upper extremity (dorsal 

aspect) . . . . , . . . . . .311 

3. Area affected by sensory changes in grave lesions of the ulnar 

nerve. Black, total anaesthesia ; grey, hypaesthesia to pricking ; 
anaesthesia to heat and cold . , " . . . . .311 

4. Peripheral sensory distribution of the lower extremity (anterior 

aspect) 312 

5. Peripheral sensory distribution of the lower extremity (posterior 

aspect) . . . . . . . . . . .312 

6. Peripheral sensory distribution of the lower extremity (external 

aspect) . 313 

7. Peripheral sensory distribution of the lower extremity (internal 

aspect) . .' 313 

8. Peripheral sensory distribution of the foot 314 



XX 



LIST OF ILLUSTRATIONS 

Motor points {after Erb) 



9. Motor points of face and neck 
10. ,, ,, anterior thigh muscles 



11. 
12. 
13. 
14. 
15. 



leg 



l'A<;E 

. 319 

. 320 

. 320 

. 321 

. 321 

322 

abdominal wall ...... 322 



at back of thigh and leg 
of upper limb 



The Effects of High Explosives upon the Central 
Nervous System 

The effects of high explosives upon the central nervous 
system fall into three groups — 

1. Immediately fatal either from pieces of shell, stones, 
rocks, or portions of buildings striking the individual, 
causing instant death, or burial of the person in a dug- 
out or after the explosion of a mine. Instant death must 
have occurred in groups of men in trenches, dug-outs or 
concrete pill-boxes from the effects of shell fire, or bombs 
employed now so largely in offensive aerial warfare, and 
yet no visible injury has been found to account for it. 
This matter will be discussed more fully later. 

2. In Group 2 we can place those cases in which the 
detonation of high explosives has caused wounds and 
injuries of the body, including the central nervous system, 
which have not been immediately fatal. The number 
of these cases which do not exhibit any of the functional 
disorders and disturbances characteristic of what is termed 
" shell shock " without visible injury, although such 
individuals have received most serious and fatal wounds 
from exploding shells, leads one to consider that in a large 
proportion of cases of shell shock without visible injury 
there are other factors at work in the production of the 
nervous symptoms besides the actual aerial forces generated 
by the explosive. 

3. The third group includes affections of the central 
nervous system without visible external injury. 

The causes of shock to the nervous system by high 
explosives may be considered under two headings : — 



2 WAR NEUROSES AND SHELL SHOCK 

(1) Physical trauma — concussion or " commotio cerebri " 
by direct aerial compression followed by decompression 
or by the force of the aerial compression blowing the person 
into the air or against the side of the trench or dug-out; 
or by blowing down the parapet or roof on to him, causing 
concussion; or a sandbag hitting him on the head or 
spine might easily cause concussion without producing 
any visible injury. Again, he might be buried and partly 
asphyxiated or, under certain conditions, suffer from 
deoxygenation of his blood by CO poisoning, for, as will 
be shown later, these high explosives generate considerable 
quantities of CO, which is inodorous and would not be 
recognised. A man lying unconscious or even conscious 
and partly buried and unable to move would be very liable 
to be poisoned by CO and not know anything about it ; 
nor would the rescuers, as the poisonous effects of the gas 
depend upon the amount in the atmosphere and the length 
of time to which the individual is exposed to it. 

(2) Psychic trauma. — The psychogenic factor is by far 
the most frequent and important cause of shock followed 
by a psychoneurosis, particularly hysteria. This factor is 
complex in its origin, being dependent in a great measure 
upon the personality of the individual soldier, his mental 
attitude, and bodily condition at the time of the shock 
(whether of emotional or commotional origin) which led 
to his collapse. 

In many cases of shell shock followed by a psychoneu- 
rosis the history shows that both physical and psychic 
trauma had combined to bring about the incapacity for 
which the soldier had been evacuated. 

" Shell shock " is a useful term if it is limited to cases 
where there is definite evidence of a shell or bomb bursting 
near enough to knock the man down, or blow him up in the 
air and cause a temporary loss of consciousness. According 
to Leri a large shell bursting within ten metres will pro- 
duce commotional shock. The effect is more severe if 



CEREBROSPINAL FLUID AND SHOCK 3 

it bursts in a closed space such as a dug-out, or narrow 
trench. Army Form W. 3436 now accompanies the man 
with a description of the occurrence. This was found to 
be essential, for true shell shock is very properly recog- 
nised as a " battle casualty " and entitles the patient to 
a gratuity. Moreover, it is very important to recognise 
the fact that a man who has suffered from true shell 
shock is not fit to return to general service for six months 
at least, and in many instances not at all. 

A Brief Survey of the Dynamic Conditions of the 
Central Nervous System, Especially in Relation 
to the Cerebro-Spinal Fluid and Shock 

The whole central nervous system is contained in a 
dosed space, the walls of which are formed by the cranium 
and spinal column, inside of which is the stout dura mater. 
Within this closed space is the cerebro- spinal fluid, which 
fills up all the space not occupied by blood-vessels or 
tissues. The cerebro-spinal fluid thus serves to equalise 
the pressure throughout the whole cranio -spinal cavity; 
moreover, at the base of the brain, where the vital centres 
of the medulla are situated, it acts as a water cushion, 
protecting them from the shock of commotion and concus- 
sion. The cerebro-spinal fluid also serves as a self-adjusting 
mechanism by maintaining a uniform equalisation of the 
blood supply to the nerve elements during the rhythmical 
variations of respiration and circulation. Now this fluid 
is incompressible, and under ordinary conditions of pressure 
from without it serves as a perfect protective mechanism, 
but when large quantities of these high explosives are 
detonated an enormous aerial compression is instantly 
generated, and it is quite possible that this may be trans- 
mitted to the fluid about the base of the brain and cause 
shock to the vital centres of the floor of the fourth ventricle, 
causing instantaneous arrest of the functions of the cardiac 



4 WAR NEUROSES AND SHELL SHOCK 

and respiratory centres. Lord Sydenham, one of the 
highest authorities on the dynamics of explosives, concludes 
that the forces generated are sufficient to cause instantane- 
ous death, and he has informed me that in the American 
Medico-Military Report it is stated that " an aneroid 
showed that the explosion of one of these shells caused a 
sudden atmospheric depression of about 350 mm. of the 
mercury tube, corresponding to a dynamic pressure of 
about ten tons to the square yard." One effect of this is 
to liberate air suspended in the blood and transform it into 
bubbles of gas which arc driven into the capillary vessels 
and cause instant death. The writer, Surgeon Fauntleroy, 
is not satisfied with the explanation, which " does not take 
into account the primary air compression by which men 
are sometimes hurled into the air. He (says Lord Syden- 
ham) considers, as I do, that the blow on the body, espe- 
cially over the heart and abdomen, may cause instant 
death. Experiments upon animals have shown that the 
sudden compression and decompression produces rupture 
of the air vesicles of the lungs and haemorrhage. This may 
occur in man" {vide p. 38). I have had officers under my 
care who have been blown in the air considerable distances. 
One Royal Army Medical Corps officer told me he was 
blown thirty feet; another told me that he was blown a 
considerable distance in a communication trench and lost 
consciousness for some time; another told me that the 
effect was like a violent push of irresistible force with a 
down cushion. But I shall have occasion later to refer 
to this explanation of suxiden death when considering the 
various theories regarding the cause of death of groups 
of men found in postures and attitudes of the last act of 
life. If aerial concussion by the forces generated by high 
explosives can cause death without visible injury, I 
think probably it would arise from sudden arrest of the 
medullary centres. The stem of the brain, surrounded 
by the cerebro-spinal fluid, is prevented from oscillating 



THE NEURON DOCTRINE AND SHOCK 5 

by the nerves which issue from it to pass through the holes 
in the skull ; likewise the spinal cord, by the anterior and 
posterior roots and the ligamentum dentatum, is prevented 
from oscillating. A sudden shock of great intensity would 
be transmitted through this incompressible fluid, and, seeing 
that it not merely surrounds the central nervous system 
but fills up the ventricles and central canal and all the 
interstices of the tissues, serving as it does the function of 
lymph, it follows that a shock communicated to the fluid 
of sufficient intensity would make itself felt on all the 
neurons. When this was written I had not the knowledge 
which I now possess of changes in the central nervous 
system as a result of shell shock, but, as the evidence {vide 
pp. 36-71) tends to support the view I took when I 
delivered the " Lettsomian Lectures " in February 1916 
to the Medical Society, I have not deemed it advisable to 
alter the original text. 

I have, however, from a far greater experience come to 
recognise the fact that the psychogenic factor is the pre- 
dominant causal agent in " War Psychoneuroses," and 
that a large proportion of cases which were regarded as 
shell shock did not owe their condition to any pathological 
changes which would have been recognisable in the central 
nervous system by any known methods of microscopic 
investigation; in fact, they were functional psychoneuroses. 
The psychogenic factor and the part it plays is fully dis- 
cussed on p. 130. 

The Neuron Doctrine in Relation to " Shock " and 
the Theory of Diaschisis ^ 

The central nervous system consists of innumerable 
anatomically distinct nervous units. Each consists of a cell 
with branching processes; there is one process the axon, 

^ The full account of the theory of diaschisis is set forth by von Monakow 
of Zurich in his recent great work, Die Lokalisation im Grosshirm, und der 
Abbau der Funktion dutch kortikale Herde, 1914. 



6 



WAR NEUROSES AND SHELL SHOCK 



the remaining processes are termed dendrons. The axon 
and dendrons are conductile; the chemical changes inci- 
dental to nervous action almost entirely occur in the cell 
and at the synapse or junction of the terminal fibrils of the 




Fig. 1. — Diaschisis. EN, effector neuron of voluntary movement; H, 
seat of haemorrhage in internal capsule causing shock transmitted to 
terminals in reflex arc of spinal cord; TD. temporary intercalary 
dissociation of reflex by shock. 

axon of one neuron with the intercalary neurons. There 
are two types of neurons, the first type of Golgi, in which 
the axon leaves the grey matter to become surrounded by 



THE NEURON DOCTRINE AND SHOCK 7 

a myelin sheath to enter into the formation of the white 
matter, and the second type, in which the axon never leaves 
the grey matter ; these are the intercalary neurons (Fig. 1). 
They always intervene between neurons of the first type, 
and in the cerebral cortex they form definite layers espe- 
cially well developed in the sensory projection centres, 
e.g., of vision and hearing. I will endeavour to show how 
retraction of the branching processes of these intercalary 
cells would shut off consciousness of the external world. 

The whole of the neurons of the central nervous system 
may be primarily divided into these two groups : (1) Neu- 
rons of the first type, which may again be divided into 
sensory or afferent projection, motor or efferent, and 
association neurons. (2) Neurons of the second type 
or intercalary. To take a few typical examples of the 
influence of shock affecting one part of the central nervous 
system and thence transmitted through anatomically and 
functionally correlated neurons to remote parts : in 
haemorrhage into the internal capsule we have a sudden 
irruption of blood cutting through the pyramidal efferent 
system of fibres, resulting in a flaccid paralysis of the 
opposite limbs (Fig. 1); the shock effect has been trans- 
mitted to the intercalary neurons at the base of the posterior 
horn of the spinal cord, and for the time being it has sus- 
pended the normal reflex tonus, that is to say, dissociation 
of the sensory projection fibres of the reflex arc has occurred. 
But we know that as soon as the shock effect has passed 
off a spastic condition supervenes on the flaccid. The 
reason of this is that the normal inhibitory cortical influence 
has been interrupted and, association of the sensory afferent 
and motor efferent in the reflex arc having been restored 
by a return to normal function of the intercalary neurons, 
the reflex tonus is increased by withdrawal of the cortical 
inhibitory influence. Let us take another example of 
which I have seen several : a bullet wound of the occipital 
region of the skull causes complete blindness, but not 



8 WAR NEUROSES AND SHELL SHOCK 

deafness. After a time the patient is left with hemianopsy ; 
the fact that the wound did not produce deafness shows that 
it was not general shock to the brain that led to the opposite 
occipital lobe being temporarily put out of function (Fig. 2). 
The two occipital lobes are anatomically and functionally 
correlated, and the injury of one lobe caused a functional 




Fig. 2. — Diaschisis. O, injured occipital lobe ; AF, association fibres 
through which shock effect is transmitted to opposite occipital lobe ; 
Ai, fibres of splenium ; II, two layers of intercalary cells — (a) associa- 
tion, (6) sensory receptors ; SP, sensory projection ; CSR, crossed 
sensory receptor fibres ; DSR, direct sensory receptor fibres. 

dissociation by the shock effect having been transmitted 
through the association fibres of the splenium. This 
temporary dissociation by shock of anatomically and 
functionally correlated systems of neurons has been termed 
by von Monakow diaschisis. 



The Living Neuron in Relation to Shock 
The researches of Ross Harrison on the living neuron 
and its growth render it possible to accept as a provisional 
hypothesis the theory of attraction and retraction of den- 



THE EFFECTS OF SHOCK ON THE NEURON 9 




Fig. 3. — Five cells from a case of a man who lived eight hours after receiving an 
electric shock of 20,000 volts. A very diffuse chromatolysis with loss of basophile 
staining substance, thereby revealing the intracellular and intranuclear networks, 
is observed. Polychrorne staining. (Magnification 810.) 



10 WAR NEUROSES AND SHELL SHOCK 

drons as an explanation of association and dissociation. 
The intercalary neurons may, indeed, possess amoeboid 
movement. A study of the living neuron shows that 
totally erroneous ideas may arise if we are guided by the 
appearances presented by the neurons in sections after they 
have been submitted to hardening and fixing reagents. 
Especially is this so in respect to the effects of shock by 
concussion generated by high explosives. The remarkable 
observations of Colonel Gordon Holmes on gunshot injuries 
of the spine causing concussion of the spinal cord without 
penetration of the dura mater by the projectile show the 
importance of a consideration of the living neuron. The 
force of the concussion produces most extraordinary 
changes in the axons, which become enormously swollen. 
The condition of the nerve cell may be studied in sections 
by two methods, in one of which fibrils can be demonstrated 
by the silver method of Ramon y Cajal ; the other by which 
a basophile staining substance (the Nissl granules) forms a 
pattern around the nucleus. The neuron, when damaged 
by injury or disease, shows various changes in the appear- 
ances of the cells whether the fibril method of staining be 
adopted or the Nissl granule method, e.g., if the processes 
of the cell be cut, the living neuron is wounded, and the 
body of the cell after it has been killed by the process of 
fixation and hardening, exhibits changes ; likewise, if the 
neuron has been damaged by a poison, changes are seen, 
but there is nothing specific about these changes, e.g., one 
could not recognise any difference in the perinuclear 
chromatolysis of lead encephalitis, alcoholic psychosis, 
experimental anaemia and section of the axons of nerve 
cells. The Nissl granules of basophile substance, as I 
pointed out in the Croonian Lectures, 1900 ^ — " On the 
Degeneration of the Neuron " — do not exist in the living 
cell. Nevertheless, the amount of this basophile staining 
substance in the form of Nissl granules may be regarded as 
1 The Lancet, June 23, 1900, p. 1779. 



THE LIVING NEURON AND SHOCK 



11 



evidence of the amount of energy substance (neuro-poten- 
tial) which the cells possessed during life (Fig. 3). In 
the healthy cell it is continually undergoing disintegration 
and automatic reintegration. When the cell is damaged, 
metabolic equilibrium is no longer maintained, and its 
osmotic surface-tension is altered, and water passes into 
the cell causing it to swell, displacing the nucleus, and caus- 
ing an appearance of chromatolysis. But this basophile 
staining substance which forms the Nissl granules does not 
exist as such in the living cells. If the living cell be 




Fig. 4. — Anterior horn cell of spinal cord examined immediately after 
death by direct illumination. The grey matter was teased in cerebro- 
spinal fluid and the preparation examined on a warm stage. The 
cell is seen to possess no Nissl bodies, but is filled with dark granules 
like an emulsion. (Obj. 4 mm., oc. 4.) • „ 



examined by direct illumination, no Nissl bodies are seen 
in the cytoplasm, only fine dark granules like an emulsion 
(Fig. 4). If living cells are examined microscopically 
with dark-ground illumination (Fig. 5), they are seen to 
be filled with small granules or globules, each of which 
after escaping from the cell remains discrete. They are 
refractile, and appear white and luminous; this is due 
to a delicate covering film of a lipoid substance which 
encloses a colloidal fluid, probably consisting of a solution 
of salts and cell globulins. When the cell dies this colloidal 
fluid is coagulated, and the precipitated proteid substance 
is massed together into little blocks — the Nissl granules; 
the intervening denser colloidal substance is continuous 



12 



THE LIVING NEURON 




O to 5 (-( 

" », "2 4> 

^ =: ® o S 

^; « X J= j; 



THE LIVING NEURON AND OXYGEN 13 

with the colloidal substance of the axon and dendrons. The 
film that covers each globule is stainable by vital methyl- 
ene blue, and a living nerve cell stained by vital blue 
presents the appearance of an emulsion of minute faintly 
blue globules. If the living cell thus stained be kept in 
an atmosphere of nitrogen in a warm chamber the stored 
oxygen is used up and a leuco-base is formed, causing 
the globules to lose their colour, and the cells appearing of 
a greenish tint. On admission of oxygen the living cell 
again becomes blue. It thus appears possible ^ that these 
granules represent a large oxygen surface, like spongy 
platinum, within the cell. When the cells die, the lipoidal 
film of the globulin-containing fluid is destroyed, coagula- 
tion occurs, and the Nissl granules are formed. These 
facts accord with the knowledge that stimulation of a piece 
of nerve causes practically no metabolic change or using up 
of oxygen, therefore the mere conduction of a stimulus 
along a nerve does not entail loss of neuro-potential. The 
chemical processes incidental to the using up of nervous 
energy in the neuron take place in the cell itself and at the 
synapses of the terminal fibrillge, and for this reason it is 
that the blood supply of the grey matter is six times that 
of the white matter. In all active neural processes oxygen 
is used up and carbonic acid is produced which escapes into 
the circumambient cerebro-spinal fluid. One stimulus 
differs from another that is discharged into a cell by varia- 
tion in modes of motion, and it is conceivable that the 
granules which fill the cell are sensible to the varying modes 
of motion, and an oft-repeated stimulus suffices by the 
establishment of a biorhythm in the cell to pass through 
to the intercalary neuron with little expenditure of neuro- 
potential, whereas a new stimulus which requires a concen- 
tration of attention must be either transformed or rein- 

^ The experiments relating to the living cell were commenced before 
the war, and I have not had time or opportunity to prosecute this research 
further ; I therefore put forward this hypothesis tentatively in my 
Lettsomian Lectures, 1915. 



14 WAR NEUROSES AND SHELL SHOCK 

forced before connection of the terminals of Neuron I with 
Neuron II (see Fig. 1) can take place, and this involves a 
using up of neuro-potential. Severe concussion can not 
only cause immediate dissociation of the cortical perceptor 
neurons, producing unconsciousness or a disturbance of 
consciousness, but for a varying period of time it can 
destroy the power of recollection of perceptions prior to 
the shock. There is a retrograde amnesia, and in very 
severe cases of shell shock, as I shall point out later, there 
may be a complete, loss of memory both as regards recol- 
lection and recognition. The loss of recollection may be 
attributed to dissociation of the higher association systems 
of pyramidal neurons which form a sheet of cells of three 
layers covering the whole cortex cerebri. The loss of 
recognition may be attributed to a dissociation between the 
cortical perceptor systems of neurons, and in complete 
loss of consciousness of the external world there is dissoci- 
ation of all the afferent projection fibres of subcortical 
neurons from the perceptor systems of neurons. Functional 
blindness and deafness, which often persist when conscious- 
ness returns, may be due to one afferent system remaining 
dissociated. 

But why, it may be asked, do we find varying degrees of 
retrograde amnesia associated with loss of recollection of 
recent experiences, while those of earlier life may be pre- 
served ? Shock so severe, or toxic influences such as 
alcohol, do not cause dissociation of the neurons in which 
habitual actions by frequent repetition have been regis- 
tered, and their revival requires a much less expenditure of 
neuro-potential the more they have become habitual and 
instinctively automatic. For the same reason the earlier 
experiences have been stored in memory, the more do they 
form the foundation upon which associative memory rests, 
for consciously and unconsciously these early experiences 
have been exerting continually their influence on the sub- 
conscious mind by association, and at the same time they 



OXYGEN AND CONSCIOUSNESS 15 

have determined and been correlated with habitual and 
instinctive actions, requiring but little conscious effort and 
expenditure of neural energy. 

The delicate granules filling the nerve cells have been 
termed " neuro-bions," as if they were independent living 
units, but this is theory. It is, however, conceivable that 
violent concussion transmitted to the cerebro-spinal fluid, 
which forms the circumambient medium of such a complex 
mechanism as the living nerve cell, could cause a violent 
oscillation of these neuro-bions and a loss or disturbance of 
their functions of variable duration according to the 
severity of the shock. 

Oxygen and Consciousness 

It is known that a continuous supply of oxygen is essen- 
tial for consciousness. The bulk of the cortex is supplied 
by the internal carotid arteries; compression of these 
arteries causes loss of consciousness in about five or six 
seconds. Histological investigation tends to show that 
the intercalary neurons have no store of oxygen in their 
cytoplasm; they depend, therefore, upon a continuous 
renewal of the oxygen in the circumambient fluid ; conse- 
quently, as soon as the capillary circulation ceases, they 
feel the effect of lack of oxygen and cease to function, 
causing dissociation to occur. It may be hypothecated 
that a violent emotion such as fright can, by its in- 
fluence on the vaso-motor centre and the heart's action, 
causing a fall in the blood pressure, produce an im- 
mediate lowering of oxygen tension in the fluid, and 
thereby suspension of function of the intercalary neurons 
of the cortex, followed by dissociation of the cortical 
perceptors and loss of consciousness. In many of the 
disorders of functions and loss of functions of the central 
nervous system resulting from shell shock, using that term 
in its widest sense, there occur symptoms of cortical 



16 WAR NEUROSES AND SHELL SHOCK 

dissociation — e.g., cortical blindness, deafness, mutism, 
and paralysis. 

The symptoms of headache, weariness, loss of power of 
concentration, irresolution and mental fatigue, constituting 
a neurasthenic condition so frequently found as a result of 
shell shock, may be explained by the acquirement of the 
habit of drawing on the reserve of neuro-potential, and 
being unable through insomnia or sleep disturbed by terri- 
fying dreams, worry, and anxiety to restore the balance and 
return to the normal conditions of automatic renewal of 
nervous energy as fast as it is used. 

Physical Shock and Psychic Shock 
Physical shock accompanied by horrifying circumstances, 
causing profound emotional shock and terror, which is con- 
templative fear, or fear continually revived by the imagin- 
ation, has a much more intense and lasting effect on the 
mind than simple shock has. Thus a man under my care, 
who was naturally of a timorous disposition and always 
felt faint at the sight of blood, gave the following history. 
He belonged to a Highland regiment. He had only been 
in France a short time and was one of a company who 
were sent to repair the barbed wire entanglements in 
front of their trench when a great shell burst amidst 
them. He was hurled into the air and fell into a hole, 
out of which he scrambled to find all his comrades lying 
dead and wounded around. He knew no more, and for 
a fortnight lay in hospital in Boulogne. When admitted 
under my care he displayed a picture of abject terror, 
muttering continually " no send back," " dead all round," 
moving his arms as if pointing to the terrible scene he 
had witnessed. 

Different Forms of Shock. Theories of Causation 

According to Crile the essential pathology of shock is 
identical, whatever the cause. Crile further says — 



PHYSICAL SHOCK AND PSYCHIC SHOCK 17 

"... When the kinetic system is driven at an over- 
whelming rate of speed, as by severe physical injury, by 
intense emotional excitation, by perforation of the intes- 
tines, by the extension of an abscess into a new territory, 
by the sudden onset of an infectious disease, by an over- 
dose of strychnine, by a Marathon race, by a grilling fight, 
by foreign proteins, by anaphylaxis; the result of these 
acute exacerbations of the kinetic system is clinically 
designated shock, and according to the course is called 
traumatic shock, drug shock, etc." 

Had Crile written this passage in the last year or two he 
would have added " shell shock." 

There are two forms of shock, viz. Primary — when the 
exciting cause produces an immediate collapse, and 
Secondary, when it comes on some hours later. 

There are many theories regarding the causation of 
shock, but whatever theory is accepted a refractory 
condition of the vital autonomic centres of the medulla 
must exercise a predominant influence in the causation 
of shock. 

Von Monakow, in discussing the subject of shock in 
relation to diaschisis, points out that in apoplectic shock 
the vital centres of the medulla (cardio-vascular and 
respiratory) are unaffected. 

In surgical shock he says microscopic investigation 
affords no satisfactory evidence of the cause of death. I 
have recently received four brains of soldiers who died 
from severe wound shock. All exhibited to the naked eye 
evidence of marked cerebral anaemia, and three out of the 
four were very soft and oedematous — a condition very 
similar to that which is found in experimental anaemia of 
the brain in animals. 

There are two theories of shock, the vascular and the 
neuro-pathological. 

The supporters of the former attribute the shock effects 
to the sudden fall of blood-pressure, general vascular 
paralysis, caused by a reflex vagus irritation and arrest 



18 WAR NEUROSES AND SHELL SHOCK 

of the heart's action in diastole. Vascular paralysis, how- 
ever, von Monakow asserts, cannot possibly explain all 
the phenomena of shock. 

Goltz favoured the neuro-pathological origin of shock, 
and considered that it was the result of excessive stimula- 
tion of sensory nerves whereby severe molecular changes 
were induced in the nerve cells. 

In wound shock the most essential cause would appear 
to be a harmful excitation of the autonomic centres of 
the medulla (cardio-vascular and respiratory), so that 
they become refractory to the normal physiological ex- 
citation, and this occurs without any microscopic histo- 
logical change in the nervous centres. This may be true 
for primary shock in which fatal collapse immediately 
follows the excitation, but not for secondary shock {vide 
pp. 38-46). 

Sight and hearing may be the avenues of excitation in 
exceptional circumstances in which psychic shock produces 
fatal collapse, in contradistinction to surgical shock, in 
which painful stimuli are conveyed to the brain and pro- 
duce a refractory condition of the medullary autonomic 
centres. The influence of the emotions on the autonomic 
centres and the endocrine glands is well known. The 
psychology of the emotions, according to the James, 
Lange, Sergi theory, is that the feeling of the emotion 
does not precede but follows the reaction of the autonomic 
centres. Whether this theory be true or not, it is certain 
that the emotion is, as the word implies, the sum of the 
effects of the excitation producing feelings of which we 
are conscious. The perceptual feelings which arouse the 
emotion of anger and fear excite or inhibit the functions 
of these medullary centres. In psychic shock a persist- 
ence of the refractory condition of the vital centres may 
occur; so that if we assume that psychic shock is 
primarily due to a reflex nervous excitation producing 
a refractory condition of the vital autonomic centres, the 



THEORIES OF CAUSATION OF SHOCK 19 

consequent sudden fall of blood-pressure is the explana- 
tion of the loss of consciousness. But the autonomic 
centres not only control the circulation and respiration, 
but also the endocrine system of glands, and Crile brings 
forward considerable evidence to show that there is an 
interrelation of the brain, the thyroid and the adrenals, 
which may be regarded as the master key to the auto- 
matic actions of the body, that is " through the special 
senses, environmental stimuli reach the brain and cause 
it to liberate energy which directly or indirectly activates 
certain other organs and tissue, amon^ which are the 
thyroids and adrenals." 

The work of Cannon and Elliot has shown that in anger 
and fear there is an increased quantity of adrenalin dis- 
charged into the circulation. The instinctive protective 
reaction in a struggle for life is either fight or flight, both 
of which require an increased activity of the whole neuro- 
muscular system. The adrenalin raises the blood-pressure 
and mobilises sugar from the glycogen store in the liver. 
This automatic instinctive reaction is brought about by 
an excitation of the autonomic centres in the medulla con- 
veyed to the suprarenal glands by the splanchnic nerves. 
If, however, there is a refractory condition of these centres, 
there will be a failure to liberate neural energy, and the 
signs of paralytic fear or psychic shock will be the result. 

An important cause of shock according to Crile is 
exhaustion of neural energy ; he attributes this exhaustion 
partly to accumulation of fatigue products causing an 
acidosis. He also lays great stress upon the exhaustion 
of the functions of the adrenal glands in the production 
of neural exhaustion. 

Crile has described the disappearance of the Nissl 
granules in the Purkinje cells of the cerebellum in shock, 
and especially has he noted that the cytoplasm of these 
cells stain with the acid eosin dye rather than the basic 
dye. I have found the same cell changes in cases of shell 



20 WAR NEUROSES AND SHELL SHOCK 

shock and traumatic shock from an extensive burn, a fact 
which supports Crilc's theory that there is exhaustion of 
the kineto-plasm of the Purkinje cells which are rightly 
believed to play an important part in reinforcing muscular 
action. 

Moreover, the apparently more marked chromatolytic 
changes found in the cells of the vago-accessorius nucleus 
than in the cells of the adjacent hypoglossal nucleus, 
point to exhaustion of the kinetoplasm in neurons which 
are active during immobility of the skeletal muscles. But 
too much importance cannot be attached to this obser- 
vation, for the cells of the vago-accessorius nucleus in the 
normal condition do not show the Nissl granules so well 
as the larger cells of the hypoglossal nucleus ; consequently 
the disappearance of the granules may occur more readily 
under the same conditions. It is difficult to estimate the 
influence of neural exhaustion resulting from activity per se 
by comparative histological appearances of different groups 
of functionally different nerve cells. However, the histo- 
logical examination of the central nervous system in these 
cases of shell shock, wound shock and shock from extensive 
bums, shows that a fall of blood-pressure and consequent 
anaemia of the brain is the most important factor in the 
production of fatal shock. 

BayHss in his recent Lectures on " Intravenous Injection 
in Wound Shock " discusses the question : " What is the 
actual nature of wound shock, and especially what is the 
immediate cause of the low blood-pressure apart from 
haemorrhage ? " He admits that it is still obscure, but he 
excludes the following conditions. 

Acapnia (diminished Carbon Dioxide in the Blood), 
because the respiration is not of such a kind as to result 
in excessive removal of carbon dioxide. 

Adrenal Exhaustion, because adrenalin is in excess 
in the blood when shock comes on. May this, however, 
not be due to the fact that it cannot be utilised ? 



THEORIES OF CAUSATION OF SHOCK 21 

Exhaustion of Nerve Centres, because reflexes are 
not diminished to any important degree except when the 
blood-pressure has remained at a low level sufficiently 
long to paralyse the centres from want of oxygen. 

Insufficient Action of the Heart, because when the 
arterioles are constricted by a dose of adrenalin the heart 
is quite able to raise the blood-pressure to a high level. 
But if, as is stated, there is excess of adrenalin in the blood 
when shock comes on, why does not this maintain the 
efficiency of the heart' s action ? 

Paralysis of Arterioles or Veins, especially of 
THE Abdominal Area, " because direct observation in the 
course of abdominal operations fails to show any abnormal 
distension." 

He admits that the cause of shock is still obscure, but 
favours the Excemia hypothesis of Cannon; which is " that 
there is an accumulation and stasis of blood in capillary 
areas so that it is removed from currency as effectively 
as if lost to the exterior." Whether there has been 
haemorrhage or not, there is a deficiency of blood in the 
circulation, and the result of this is that there is a low 
arterial pressure and a failure to supply the tissues with 
their normal requirements in oxygen. 

The pathological changes which take pJace in cells when 
insufficiently supplied with blood are well known, and 
Bayliss cites : " The suppression of renal secretion, the 
failure of cardiac contraction below about 90 mm. of Hg. 
(Marckwalder and Starling) and the changes in the nerve 
cells." In cats he finds that the vaso-motor centre loses 
its reflex excitability after one or two hours of an arterial 
pressure of 60 mm. The respiratory centre fails earlier. 
Many of the symptoms of shock disappear when the blood - 
pressure is raised. His experiments show that it is im- 
portant to increase the blood supply and oxygen supply 
to the tissues, especially to vital organs such as the nerve 
centres and the heart. 



22 WAR NEUROSES AND SHELL SHOCK 

His conclusion regarding acidosis as a cause of shock is 
summed up in the following sentence : " On the whole I 
am compelled to conclude that ' acidosis ' is not in itself a 
serious factor in shock, and that alkaline injections are not 
called for." 

He recommends the intravenous injections of gum 
solution for the treatment of wound shock. He deprecates 
the use of vaso-constrictor drugs, for, apart from their 
transitory effects, the result is actually a diminished blood 
supply to the tissues, because the rise of blood-pressure is 
obtained by narrowing the arterioles which convey. 

Doubtless a combination of factors is responsible for 
traumatic shock. There is a great difficulty in differ- 
entiating the symptoms of emotional from commotional 
shock. The absolutely sudden onset of emotional shock 
by a horrifying sight, apart from war conditions, can only 
be explained by a sudden fall of blood-pressure, by arrest 
of function of the vaso-motor centre. This fall of pres- 
sure is followed by cortical anaemia causing loss of con- 
sciousness and cortical dissociation, which dissociation in 
a neuropath may persist in whole or in part, causing 
psychic deafness, blindness, mutism and amnesia. 

If we accept Crile's theory we can understand why a 
normal neuro -potentially sound individual may from 
prolonged stress of war become so run down in kinetic 
reserve energy that an emotional shock suffices eventually 
to produce collapse, which, if not fatal, at any rate causes 
a condition of neurasthenia of considerable intensity and 
duration. 

I have been struck by the fact that quite 10 per cent, 
of the cases of shell shock have presented mild symptoms 
of Grave's disease, an indication that the endocrine glands 
are profoundly affected. 



HIGH EXPLOSIVES AND PROJECTILES 23 

The Nature of High Explosives and Forms of 
Projectiles 

Sir Anthony Bowlby, in the Bradshaw Lecture on 
" Wounds in War," ^ called attention to the nature of 
high-explosive shells and their terrible effects. " These 
shells vary in weight from a few pounds to about a ton, and 
they consist of a thick iron case containing in a central 
cavity a violent explosive charge. The latter is, in the 
case of German shells, trinitro-toluene, and may contain as 
much as 200 lb. of this explosive. Such shells are burst 
upon percussion by a detonator, which acts by the impact 
of the shell upon the ground or on some other object. 
These shells do not contain bullets, and the injury they do 
is in chief part by the jagged fragments into which they 
are split by the explosion, and also to some extent by the 
impact of portions of buildings, such as stones or bricks, 
which are scattered with immense force by the violence of 
the explosion. [He might have added sandbags forming 
the parapet of a trench or the roof of a dug-out.] The 
fragments of the shells are always very rough and jagged 
and of every variety of size and shape. For example, the 
base of a 17-inch shell may weigh 150 lb., and if it struck the 
body of a man would completely destroy it. Other frag- 
ments may weigh a few pounds and may tear off a limb or 
crush it to pulp, while in the smaller shells there may be 
scores of fragments about the size of the end of the finger 
or much smaller. It must also be borne in mind that the 
mere explosive force of the gases of a large shell exercises 
great powers of destruction. The expansion of the gases 
is sufficient to kill, and in the only case in my experience 
in which an autopsy has been made the brain was the seat 
of very numerous petechial haemorrhages." This brain, 
by the kindness of Professor Arthur Keith, has come into 
my possession, and the result of the microscopic examina- 

1 The Lancet, TtecemheT 25, 1916, p. 1385. 



24 WAR NEUROSES AND SHELL SHOCK 

tion I shall deal with fully later. Suffice it to say that 
the appearance it presented led me to suspect CO poison- 
ing. But high explosives are used also in mines, and in 
various other forms of projectiles, such as bombs of im- 
mense size dropped by aeroplanes, aerial torpedoes, whizz 
bangs, and grenades. It is, however, the big shells, bombs 
and mines which are so deadly in producing fatal or serious 
effects on the central nervous system without visible external 
signs of injury. 

The following cases show the great force generated by 
high explosives : — 

A lieutenant under my care told me that he was in a communi- 
cation trench when an aerial torpedo exploded close to him. He 
felt a great pressure against him; it was soft, but sufficiently 
powerful to knock him down unconscious. He did not know 
how long he was unconscious, but thinks it must have been an 
hour. When he recovered consciousness he got up and was 
helped away. His head felt as if it would burst, and ever since 
he has had a whizzing in the left ear and dizziness. Dreams of 
bombs and aerial torpedoes bursting. There was no parapet 
to blow down on him. 

A captain in the R.A.M.C. told me that a large shell burst at 
his back and he was blown fifteen yards by the aerial disturbance. 

An R.A.M.C. officer at the battle of Ypres had a shell explode 
near him. He was not hit, but lay unconscious for six hours. 
He recollects the shock of the shell as he went out of the dressing- 
room. For some days he suffered with severe headache and 
soreness of back of head and down the spine ; the lower extremi- 
ties felt heavy, but there was no loss of feeling. He had reten- 
tion of urine for a day only, and around the body there was a 
pain like an appendix pain. He rapidly recovered. 

Theories Regarding Causation of Instantaneous 
Death of Groups of Men 

At various times, from the earliest periods onwards in 
the war, journalists have given vivid descriptions of shell 
fire causing instantaneous death of groups of men. Ash- 
mead Bartlett, in his graphic description of fighting in the 



CAUSATION OF INSTANTANEOUS DEATH 25 

Dardanelles, relates what he found in " A Valley of Death." 
" In one corner seven Turks, with their rifles across their 
knees, are sitting together. One man has his arm around 
the neck of his friend and a smile on his face, as if they 
had been cracking a joke when death overwhelmed them. 
All now have the appearance of being merely asleep ; for 
of the seven I only see one who shows any outward injury." 
How can we explain death without apparent bodily injury, 
yet so instantaneous as to fix them in the life-like positions 
and attitudes thus realistically described? Did rigor 
mortis come on immediately, and what was the cause? 
Officers and soldiers have told me that they have felt ill 
and vomited with the gases generated by these high- 
explosive shells. A Canadian officer told me that in the first 
gas attack made by the Germans he felt ill and vomited 
with the gases generated by the high-explosive shells. The 
smell has, like that of bananas, a faint sickly odour that made 
him feel ill and vomit, and quite different to the " gas." 
In considering the causation of fatal shell shock without 
visible sign of injury it is necessary, therefore, to take into 
account chemical changes in the atmosphere together with 
the physical forces generated by the explosive. The effect 
of the emanation of a poisonous gas was the explanation 
at first given for instantaneous death without physical sign 
of injury; it was widely bruited about that turpinite, 
a French high explosive, produced a deadly gas which would 
be quite capable of producing sudden death without visible 
signs of injury; but the question even then arises. Why 
should the body remain in a life-like position? Many 
authorities regard it as much more likely to be due to the 
effects of concussion on the nervous system. Cases that 
have recovered after severe concussion without visible 
sign of injury may, nevertheless, have received physical 
concussion by sandbags blown down from the parapet 
into the trench, or, if the shell burst in a dug-out, the earth 
may be driven down with great force, burying the inmates. 



26 WAR NEUROSES AND SHELL SHOCK 

A case, however, came under my care, in which there was 
no history of this happening, from No. 6 C.C.S., 24-25.9.15, 

as follows : — 

" This man was blown up by a shell and was found in the 
dug-out with his two comrades, both of whom were dead. 
While here he has been quite insensible to all questions. He has 
been in a cataleptic state, with at times convulsive seizures. 
His light reflexes are present." 

He was removed to No. 30 CCS. I., and further notes state : 
" Reflexes very active. Urine draA\Ti off one pint ; when tested 
showed marked albumin. Both pupils widely dilated. Speaks 
incoherently occasionally. There is no outward evidence of any 
injury or symptoms of pain anywhere." Five days later he was 
admitted to the 4th London General Hospital. He complained 
of a strange feeling in his head, and sweated profusely. He was 
terrified when the corporal in charge shook him to try and stop 
his shouting and mumbling. He complained of severe headache 
of the vertex, shook a good deal, and said everything in front 
of him looked blurred. He could hear and comprehend what 
was said to him, and spoke in reply to questions ; subsequently 
he made a complete recovery. 

The fact that there was albumin in the urine when it 
was drawn off and no visible sign of injury suggests that 
inhalation of noxious gases in a closed space was an import- 
ant contributory cause of the death of his two comrades and 
of the severe temporary symptoms which he manifested. 
But, it might be argued, if poisonous gases generated by 
the explosion caused death, it is only by inhalation while 
the man is lying on the ground unconscious or partially 
buried, and this would not account for the sudden death 
where groups of men are found fixed in the last act of life. 
M. Arnoux, a French civil engineer, has studied this ques- 
tion, and has suggested another theory which is extremely 
interesting. A pocket aneroid barometer carried by an 
officer had been exposed to an explosion of the kind referred 
to, and was put out of working order by the force of the 
concussion. M. Arnoux had the aneroid repaired ; he then 
placed it under the reservoir of an air pump and ej:haust 



CAUSATION OF INSTANTANEOUS DEATH 27 

until he had produced the same effect on the aneroid 
as was observed before it was repaired. He calculated 
from observations and experiments that the dynamic 
pressure exerted by the surrounding air on bodies within 
a few yards of the exploding shells had amounted to over 
10,000 kilos, per square metre. Men standing close to 
the exploding shell would be blown into the air or dashed 
against the ground with great violence, but in the case 
of men leaning against the side of a trench wall only the 
static depression could affect them. What, M. Arnoux 
asks, would be the effect on the human organism of so 
powerful and so sudden a decompression? It would, 
he answers, be similar to that which causes the deaths of 
aeronauts who make too rapid an ascent or of workers 
in compressed air caissons who leave their caissons too 
quickly and without taking proper precautions for their 
slow decompression, namely, the sudden escape from the 
blood of bubbles of air and COg, which would produce 
capillary embolism throughout the body and cause sudden 
death. M. Arnoux's theory is, then, that the sudden in- 
crease of atmospheric pressure produced by the explosion 
is capable of producing an immediate increased absorption 
of air and COg by the blood, followed by a sudden libera- 
tion on return to normal conditions. 

Surgeon-General Stevenson,^ commenting upon the 
theory of M. Arnoux, asks : " Is it possible that a sudden 
increase of atmospheric pressure, lasting only a fraction of 
a second, no matter how great it might be, could so charge 
the blood with gases that their discharge into the blood 
stream when the pressure ceases would cause death in the 
same manner as a too rapid return to ordinary atmospheric 
pressure in caisson workers ? " He advocates the theory 
of concussion of the central nervous system as the most 
satisfactory explanation ; the water jacket of the cerebro- 

^ '.' Note on the Cause of Death due to High-Explosive Shells in XJn- 
wounded Men," Brit. Med. Joum., September 18, 1915, p. 450. 



28 WAR NEUROSES AND SHELL SHOCK 

spinal fluid serves as a protection to the vital centres of the 
medulla under all ordinary conditions of commotio cerebri. 
But in these cases (as M. Arnoux's experiments prove) we 
are dealing with extraordinary conditions of atmospheric 
pressure : a pressure force which we believe is sufficient to 
cause a temporary loss of consciousness, temporary blind- 
ness, deafness, paralysis, and loss of speech without any 
visible signs of injury. If the functions of the higher 
centres are for a time instantaneously suspended by the 
shock, it is conceivable that in the severest cases the func- 
tions of the vital centres of the medulla may be instantane- 
ously suspended by its concussion ; moreover, the haemor- 
rhages in the corpus callosum and the basal ganglia found 
in the brain referred to might, accepting this view, be ex- 
plained by the fact that the ventricles are filled with incom- 
pressible fluid to which the violent shock is transmitted. 

The cases that have recovered after severe shell shock 
very rarely show signs or symptoms of organic disease. 

But suppose the air is charged with carbon monoxide 
and oxides of nitrogen, would it not be possible for the 
man to inspire enough of these gases to cause instant death ? 
I wrote to Professor Leonard Hill on this subject, and I 
received the following very interesting reply : — 

" The explosion of a big shell in a trench, dug-out, cellar, 
or other confined space must, I think, instantly deoxy- 
genate the air and produce a high concentration of carbon 
monoxide and oxides of nitrogen. The inspiration of a 
man at the moment of explosion may introduce enough 
of these gases to cause death from want of oxygen. If he 
is fatigued his muscles will be in the condition to go into 
rigor on the sudden deprival of oxygen. It would be of 
great interest to get samples of blood from men killed by 
shell shock. I do not see how the alteration of air pressure 
can do more than act on the gas in the guts and on the lung. 
The sudden compression of the lungs by several atmospheres 
must be considered. The pressure will probably act 
quicker through the wall of the thorax than down th^ 



SIGNS AND SYMPTOMS OF SHELL SHOCK 29 

trachea. I do not see how a sudden squeeze of the thorax 
is going to do any harm, and the pressure will be equally 
distributed through the fluids of the body in all directions, 
and it is not enough to break the thoracic wall by the sudden 
compression of the gas in the lungs. A copper ball with a 
glass tube sealed up full of air sunk in the deep sea is broken 
in when the glass tube bursts in spite of a free opening into 
the copper ball. I imagine the thoracic wall might be 
broken in by a sufficient sudden pressure. The elasticity 
of the atmosphere is such that this does not occur. I once 
carried out some experiments on the effect of exploding 
heavy charges of guncotton on pigs. A few feet of air was 
enough to save the pigs from damage. When the guncotton 
exploded near the ground the soil, stones, etc., were con- 
verted into missiles, and these wounded the pigs. The 
lungs of these pigs showed some patches of emphysema, as 
if the sudden wave of air pressure had driven air from one 
part of the lung into other parts. 

" I should say the men either die, as you suggest, from 
the gases — deoxygenation of blood — or else from con- 
cussion." 

Also through Lord Sydenham I have heard from the 
Secretary of the Trench Warfare Department that it is 
possible that the partial detonation of a large shell contain- 
ing, say, 50 to 100 lb. of T.N.T. would produce enough 
carbon monoxide in the immediate vicinity to give rise to 
the characteristic poisonous effects of this product. 



General Description of the Signs and Symptoms of 
Gommotional Shock 

A soldier who has an inborn or acquired emotivity will 
sooner or later suffer with a psychoneurosis. A shell 
bursts near him, he sees the flash, is blinded by it, and 
remains functionally blind, or unable to open his eyes, or 
is affected by a continuous blepharospasm; he hears the 
explosion and is temporarily deafened by the noise and 
remains deaf; this cortical sensory dissociation of the 



30 , WAR NEUROSES AND SHELL SHOCK 

centre of hearing by diaschisis causes in many cases mutism. 
He is blown up, and perhaps falls heavily on the ground, 
or is buried with earth in a crater or dug-out, or a sandbag 
hits him. When he recovers consciousness he may be 
affected with a spasmodic tic or convulsive movement of 
a defensive nature, such as the dodging reflex; or he may 
be affected with one of the many forms of hysterical 
paralysis or contracture, the result of suggestion. These 
varied and multiform hysterical manifestations are fre- 
quently grafted on to the signs and symptoms of shell 
shock. Psychogenic in origin and due to emotional 
shock, these symptoms are curable by contra-suggestion ; 
in true shell shock there is always a residual neurasthenic 
condition which persists for a long time and does not 
yield to contra-suggestion. 

When the physical forces generated by the explosion 
are sufficient to cause physical shock as well as emotional 
shock the case is then complicated by two factors, viz. 
commotional shock and emotional shock. The Army 
Form W. 3436, which accompanies the evacuated soldier, 
gives information as to whether the shell burst so near 
him as to justify the assumption that commotion was the 
essential agent in the cause of the symptoms for which 
he was evacuated ; this would be strengthened by the fact 
that he was unconscious, or so dazed as the result of the 
shock that he either had to be carried or taken to the 
clearing station, and especially would it be justifiable to 
classify the case as a " battle casualty " if he were buried 
and had to be dug out, or suffered contusions as a result 
of being blown up. Still, many' facts show that indi- 
viduals with an inborn or acquired emotivity might suffer 
so severely from " emotional shock " as to be rendered 
unconscious or so dazed as to necessitate them being 
taken or carried to the clearing station. It is, therefore, 
extremely difficult to decide from the symptoms alone 
whether the case is commotional or emotional, or both. 



DESCRIPTION OF COMMOTIONAL SHOCK 31 

For a man neuro-potentially sound, after prolonged stress 
and anxiety of trench warfare, may become emotive. 

The only way to decide is by a careful investigation of 
all the facts, notably the length of time the man has been 
on active service at the front and his conduct as a soldier 
prior to the occurrence of the shock. Another important 
piece of evidence is the loss of consciousness. The period 
of time varies from a few hours to a few days in the most 
severe cases. When consciousness is restored it does not, 
as a rule, remain clear continuously, for there may be 
relapses to unconsciousness or lethargy of mind. The 
patient (as a rule) suffers with some retrogade amnesia. 
If he recovers, or only shows neurasthenic symptoms and 
no signs of " conversion hysteria," the presumption is 
that the case is one of true shell shock, and may there- 
fore be regarded as a battle casualty. It has been found 
that in commotional cases, as distinct from purely emo- 
tional shock, the cerebro-spinal fluid shows an increased 
pressure when lumbar puncture is performed; it has also 
been found that this operation relieves cerebral symptoms, 
such as headache ; the fluid upon examination is found to 
contain albumin, and, in severe cases, blood. The reason 
for this is explicable if consideration be given to the 
microscopic investigation of the central nervous system 
in fatal cases {vide pp. 38-65). 

Description of a Gommon Type of Commotional 

Case 
When shells explode in or on a dug-out, where reper- 
cussion can take effect to a maximum degree, they cause 
much more serious shock effect than when they explode 
in the open. Following such an explosion a number 
of men may be found in the dug-out suffering with 
shell shock, and some perhaps dead, yet showing no ex- 
ternal injury. They may be seated or lying on the floor, 



32 WAR NEUROSES AND SHELL SHOCK 

crouching or curled up in various unnatural attitudes. 
Their muscles are flaccid and there is hypotony. As a 
rule they are unconscious, but consciousness may not be 
completely lost. The sphincters are relaxed, there is no 
real paralysis, but there is a lack of purpose and precision 
in their movements. The general sensibility is diminished, 
and when the disturbance of consciousness is not too pro- 
found to test the special senses it is found that all the 
perceptions are enfeebled. Those cases which are able to 
describe their visual sensations frequently complain of a 
darkness before the eyes. There is tremor in the hands, 
and the whole body may shake. As a rule both the 
cutaneous and tendon reflexes arc brisk, even exaggerated. 
It has been noted by Roselle and Oberthur that at first 
the plantar reflex is extensor, and fanning of the toes may 
be obtained. The extremities are cold; a little later, 
when they have become warm the return to normal 
sometimes occurs in an unequal and irregular manner — 
one hand being red and warm, whilst the other is cold 
and blue. The patient is bathed in a cold sweat, and 
there may be an abundant flow of ropy saliva. The pulse 
is constantly slow, small and thready, even imperceptible, 
and the heart beats rapidly. There is, in fact, a condition 
of collapse. In favourable cases when the circulation is 
re-established the heart beats energetically and carotid 
pulsation may be seen. When the patient recovers con- 
sciousness, and this is the usual course of events, he 
complains of abdominal pain, or pain at the pit of the 
stomach, as if he had had a blow of the fist, or the pain 
may be in the chest. If he coughs, his expression denotes 
suffering, and the expectoration is a frothy mucus often 
tinged with blood. There may be bleeding from the 
ears or nostrils and small sub-conjunctival hajmorrhages ; 
these signs and symptoms may not all be present, nor 
are they of equal intensity in all cases. For some days 
there is a clouding of consciousness, accompanied by 



EMOTIONAL SHOCK FOLLOWING COMMOTION 33 

severe headache and extreme lassitude. The less severe 
and more favourable cases may not be returned to the 
base, but after remaining in the clearing station a short 
time they are able to carry on, but it is quite likely that 
they will break down shortly after returning to the front 
line. 

The clouding of consciousness is persistent in the less 

favourable cases, and various psychogenic complications 
frequently arise, such as mutism, deafness, deaf mutism, 
hallucinatory delirium, or a state of mental confusion 
bordering on stupor; in the severe cases the patient 
may remain in a state of coma until death {vide p. 46) . 



Description of Severe Emotional Shock following 

Commotion 

When a shell bursts in the open a man may be blown 
some distance and yet not lose consciousness, but a sub- 
sequent horrifying sight of dead and mangled comrades 
may act as a sudden emotional shock and cause loss of 
consciousness, with marked symptoms of commotional 
shock. The following case illustrates these points re- 
markably well. Here there was no repercussion, and 
although the man was blown some distance, he did not 
in consequence lose consciousness. 

Private C R , age 21, admitted straight from France. 

He was at Boulogne two weeks. 

From his own statement he had recovered sufficiently to 
give an account of himself. It seems that this man went out 
in May 1915 and was admitted on the 28th June to the 4th 
London General Hospital, after being a fortnight in Boulogne, 
so that he could have been only a very short time, a week or 
two at most, at the front. The account he gave of his being 
knocked out is as follows : — 

He was carrying sandbags in the company of thirty men in 
daylight and under shell fire. The explosion flung him into 
a deep hole, and he climbed out to see all his friends lying 
around dead. This was his first sight of death, and he keeps 

D 



34 WAR NEUROSES AND SHELL SHOCK 

seeing it again, both awake and asleep, with bright Hghts and 
bursting shells. He does not hear the shells, but sometimes 
the men shouting. He sometimes dreams that he hears the 
shells exploding and the shouts of men. He said that he had 
always felt sick at the sight of blood. 

When admitted to the hospital he presented an aspect of 
extreme terror. He sat up in bed with eyes staring wide, 
pupils dilated, brow wrinkled, nostrils dilated, mouth slightly 
open, and muttering sounds. He moves his head from side to 
side with occasional moans and groans, and moves his arms 
as if indicating something lying on the ground, alternating this 
with a movement of his right hand to his forehead. He keeps 
saying, " You won't let me back." It is remarked that the 
movements become less when he is unobserved, and cease 
during sleep. He comprehends what is said to him. He does 
not suffer with cold or blue hands, and the pulse is fair. Some 
days later, when he was improving, he became violently agi- 
tated when he saw me with two other strange officers come 
near his bed. I told him we were doctors, and that he would 
not be sent back to the front. From this time onward he began 
steadily to improve. I came to the conclusion from his sub- 
sequent complete recovery that this man Mas naturally of a 
timorous disposition, and that his condition was largely shock 
and terror due to two causes, viz. the memory of dreams of 
his awful experiences of war, and the continuous fear of liis 
being sent back to the front. He was subsequently transferred 
to Morden Hall, where he has completely recoveied. 

JSuvtinhtr 22, 1917. 

Neurasthenia and Acquired Emotivity 

Name. — Private E F . 7th Middlesex. 

Age. — 19, 

Former Occupation. — Engine cleaner. 

Heredity, etc. — So far as the patient j knows, none of his 
family has had any nervous or abnormal tendencies. He is 
sensitive, qui?t and thoughtful. 

Army Life. — Joined up 25th July 1915. First went to 
France in May 1916. On July 5th of the same year, having 
received a slight wound in the right forefinger, and being 
'* shaken up " by shell fire, he was sent to England for Home 
Service. In March 1917, having quite recovered, he was agaui 
sent to France. Was gassed on May 3rd and sent to the Base 
Hospital, suffering from loss of sleep and pain in chest. He 
recovered and towards the end of July returned to the front 
Jines. On the 15th October, whilst out on patrol after nightfall, 



EMOTIONAL SHOCK FOLLOWING COMMOTION 35 

he accidentally shot a comrade whom he " took for a Fritz." 
This caused him great uneasiness. 

Symptoms. — He suffered from insomnia, lying awake and 
fearing to fall asleep lest he should dream of the accident. 
He also suffered from extreme depression about it. On 
October 26th he lapsed into a feverish state — which has 
been described as P.U.O. This state was accompanied by a 
continuous headache in the frontal region and by recurrent 
pains between the shoulders, below the small of the back, and 
at the posterior part of the legs. 

The patient has no doubt that his worry was the cause of 
his nervous state. 

The mixed commotional and emotional type is perhaps 
the commonest type ; according to whether we regard the 
question of shock from an organic or functional point of 
view, so may the origin of conditions met with in shell 
shock be explained. My opinion regarding the relative im- 
portance of the organic factor to the psychogenic in respect 
to the symptoms of shell shock has changed with further 
knowledge. The. psychogenic factor, in my judgment, 
is by far the most important cause of the consecutive 
phenomena. 

Those cases of shock which recover fairly quickly may 
belong to two classes of functional disease, viz. hysteria 
and neurasthenia; the former cases are usually due to 
emotional shock, the latter to stress of war and commotion, 
but hysterical and neurasthenic symptoms are combined 
in a large number of cases. 

The milder cases of shell-shock neurasthenia suffer with 
headache, insomnia, extreme sensibility to sudden noises, 
or bright lights, and many are troubled with terrifying 
dreams. They avoid crowds, they are anxious and easily 
fatigued by bodily effort, and sexual desire is diminished. 
In fact, there is evidence of an irritable nervous weakness 
combined with a mental preoccupation. 

After the initial stage the physical signs of shell shock 
are less obvious. Sensibility has returned, the locomotor 
difficulties, for the most part, have disappeared. The 



36 WAR NEUROSES AND SHELL SHOCK 

deep reflexes arc brisker than normal. The pupils are 
dilated. The circulatory troubles remain. The blood 
pressure may be above normal, and the heart-beat forc- 
ible and rapid. There may be symptoms and signs of 
exophthalmic goitre. 



Consecutive Phenomena of Shock 

Before treating of the consecutive phenomena of 
shock, whether it be of commotional or emotional origin, 
or of both, the question may be asked, Why should a 
man affected by a strong emotion of terror or horror fall 
down unconscious, and subsequently suffer with symptoms 
similar to those produced where there is actual commotion ? 
Moreover, another question is whether in the great majority 
of cases of so-called " shell shock " implying a physical 
cause the symptoms are not due to emotional shock. If 
so, they are psychogenic in orig'n and unattended by 
visible microscopic changes in the central nervous system. 
Certain cases have been recorded by Leri and others, which 
show clinically that the explosion of a large shell near a 
soldier may cause clinical signs pointing to organic disease, 
although there are no visible signs of injury. 

Leri, in the Revue Neurologique de Guerre, describes three 
cases of hjcmorrhages into the central nervous system from 
"commotion." The first case was a case of hamatomyelia 
strictly limited to the first and second sacral segments resulting 
in paraplegia with absence of mobility, sensibility and reflec- 
tivity in both feet. The second case was as follows : a shell 
burst on the left side of a man and some hours later there 
followed for the first time a right-sided Jacksonian epilepsy; 
the subject fell on his hand, his head was not struck, and he 
did not lose consciousness. The third case was one in which 
the symptoms pointed to a lesion of the optic thalamus. The 
patient threw himself down on hearing the shell coming; he 
arose soon after the explosion and found that he was hemi- 
anaesthetic ; this was followed by an oncoming of hemiplegia 
which became total with contracture; he then became uncon- 



CONSECUTIVE PHENOMENA OF SHOCK 37 

scious. The cerebro-spinal fluid contained blood. In another 
case the symptoms pointed to a lesion in the bulb. 

These, however, have not been attended by post-mortem 
examinations and microscopic examinations of the central 
nervous system. I have had the opportunity of examining 
the brains in three other cases, and as these illustrate two 
distinct types of the fatal initial stage I will describe them, 
and contrast the macroscopic and microscopic findings. 

CASE I 

Clinical Notes 

In this case a man developed (according to a note furnished 
by Captain J. London) a degree of nervousness on the Somme 
which he never lost, but was able to control for six months. 
Later, he was in an area which was subjected to an intense 
bombardment, during which, as far as can be ascertained, no 
gas shells were used. This lasted about four hours (P'ebruary 
22, 4 p.m. to 8 p.m.). Although he remarked to another man 
that " he could not stand it much longer," he did not give way 
until the following day, twelve hours later, when perhaps six 
shells came over (February 23, 8 a.m.). 

He was not buried or gassed. One shell burst just behind 
his dug-out — namely, ten feet away — in the morning, but many 
must have been as near the previous day. Early symptoms 
were tremors and general depression. The later symptoms 
(February 22) were coarse tremors of the limbs, crying (February 
23), inability to walk or to do anything. He would not answer 
questions — very like the hysterical manifestations of melan- 
cholia. The pupils were dilated. I was rather busy with 
some wounded at the time, and did not make a detailed 
examination. 

A note by Captain Francis A. Duffield, R.A.M.C. (S.R.), 
states that the man was admitted to the field ambulance in 
the evening in a state of acute mania, shouting " Keep them 
back, keep them back." He was quite uncontrollable and 
quite impossible to examine. He was quieted with morphine 
and chloroform, and got better and slept well all night. In a 
later note, Lieut. -Col. F. J. Crombie, in command of the field 
ambulance, stated that the patient had at least two hypo- 
dermic injections of morphine while in the ambulance. Next 
morning he woke up apparently well, and suddenly died. 



38 WAR NEUROSES AND SHELL SHOCK 

Now the effects of explosion in a dug-out are always 
greater than in the open, owing to the repercussion of the 
aerial compression and decompression. This commotional 
shock acting upon an individual already in an exhausted 
and emotive state was followed by an attack of acute 
maniacal excitement, and evidently visual hallucinations, 
for in his struggles he shouted out, " Keep them back," 
as if he saw Germans. So violent were his struggles that 
he had to be given chloroform and morphia injections. 
The notes state that he woke up apparently all right and 
suddenly died. Captain Stokes made the post-mortem 
examination. He noted a considerable haemorrhage in 
the substance of the lower lobe of the left lung. This 
condition may have been due to the sudden aerial com- 
pression and decompression, for similar haemorrhages have 
been observ^ed in animals experimentally subjected to the 
shock of high explosives. The right heart was enlarged 
and dilated. The muscle was good and there were no 
valvular lesions. This suggested heart failure as the cause 
of sudden death. There was a slight bruise on the scalp, 
in the frontal region. The brain was congested and 
ocdematous. There were subpial punctate haemorrhages, 
but the subcortical white matter showed no petechial 
haemorrhages. The cerebro-spinal fluid was blood-stained. 
He remarks in conclusion : " There was no gross lesion 
of the viscera, which might have been a cause of death ; 
but though I have never seen a post-mortem examination 
on a man who has died from ' shell shock,' I consider the 
condition of the brain was consistent with that diagnosis." 

Summary of Histological Changes ^ 
Vascular Changes 
The vessels of the pia-arachnoid membranes of the brain 
arc congested, and there are scattered subpial haemor- 

' The full account of these changes was published in the British Medical 
Joumal,_NovemheT 10,^1917. 



HISTOLOGICAL CHANGES IN SHELL SHOCK 39 




Fia. 6. — Haemorrhage into the sheath of a vessel in the median 
raphe of the medulla. Magnification 1 70. 



— r 



-^WsT" 



c 






t .. 



"^ 



Fig. 7.^An arteriole breaking up into capillaries with dilated 
perivascular space. This space is in communication with the 
perineuronal space around the nerve cells. Magnification 300 



40 WAR NEUROSES AND SHELL SHOCK 




Fig. 8. — Section of cortex, Case 2. Dilated perivascular space around 
collapsed arteriole and capillaries. Dilated perineuronal spaces. 
Magnification 375. 




Fig. 9. — A small vcss(M cnl longitudinally in tlio internal capsule. 1 iio 
vessel is filled with blood corpuscles ; the perivascular sheath is seen 
dilated and fiUed with red blood corpuscles. Magnification 235. 



HISTOLOGICAL CHANGES IN SHELL SHOCK 41 



rhages of microscopic size almost everywhere. In the 
white matter of the corpus callosum, the internal capsule, 
the basal ganglia, the pons and medulla, there are seen 
congested veins and haemorrhage into the sheaths of the 
vessels with occasional extravasation of blood corpuscles 
into the adjacent tissues {vide Figs. 6, 9, 10). In the lower 
part of the medulla oblongata there is a vessel running into 
the anterior median fissure and raphe which has ruptured 



5— rr— Y7-753P5 



mMM 




.-ytk*^ 



Fl(J. 10. — Hajinorrhagos into tlie white matter of the pons. 
Slagnification 90. 

and the blood has escaped not only into the sheath of the 
vessel but into the adjacent nervous tissue. This haemor- 
rhage is less than 2 mm. from the vago-accessorius nucleus 
{vide Fig. 6). 

A remarkable histological feature of this case, also of 
Cases II and III, is the evidence of cerebral anaemia. In 
many regions the vessels appear collapsed and empty, the 
perivascular sheaths are dilated and appear clear and as if 
distended with a non-coagulable fluid, presumably cerebro- 
spinal {vide Figs. 7 and 8). The appearances of the vessels, 
arterioles, venules and capillaries associated with engorged 



42 WAR NEUROSES AND SHELL SHOCK 

congested pial veins accord in all respects with the appear- 
ances presented by sections of the brains of animals 
(monkeys) which have died after ligation of both carotid 
and vertebral arteries. Inasmuch as in this case death in 
all probability occurred from heart failure, this form of 
shock resembles in many ways shock from wounds and 
extensive burns in which there is a low blood pressure, 
cortical anaemia and changes in the nerve cells of a similar 
nature to those described in these cases of shell shock. I 
have recently examined the brain of a man who died of 
secondary shock twenty hours after suffering from an 
extensive burn. He lived for some hours with imper- 
ceptible pulse. The cortical ansemia was very evident, 
for although the pial veins were very congested with 
rupture and extravasation of blood in the subarachnoid 
space, the arterioles, capillaries and venules in the brain 
substance were frequently found empty and collapsed, and 
the perivascular sheaths dilated and clear, intercommuni- 
cating with one another and the perineuronal spaces. 

The Cell Changes 

There is a generalised early chromatolytic change in 
the cells of the central nervous system. This change 
varies in intensity. The cells most affected are the small 
cells; in these the basophil substance has almost disap- 
peared. In the larger cells the Nissl granules are smaller 
and not packed so closely together as normal. The small 
cells of the medulla and pons are slightly swollen and the 
nucleus is large and clear. Some groups of cells show the 
chromatolytic change more markedly than others; for 
example, the vago-accessorius compared with the hypo- 
glossal nucleus (Figs. 11, 12). 

Sections of the cerebellum stained with thionin and 
safranin show very unequal staining of the Purkinje cells 
with theg basic dye (Fig. 13). This condition is very 



HISTOLOGICAL CHANGES IN SHELL SHOCK 43 




Fig. 11. — Cells of the vago-accessorius nucleus at the level of ^ the 
calamus scriptorius. Observe the marked chromatolysis "and 
eccentric position of the nucleus. Compare the same with Fig. 6. 
Magnification 400. 




iiG. 12. — Cells of the adjacent hypoglossal nucleus, showing early 
shght chromatolysis. Magnification 400. 



44 WAR NEUROSES AND SHELL SHOCK 




i''i(;. i;i. - Suction of eerebi'lluin, Case I, stained with polyclirouic 
and eosin. Note the Purkinje cells are not all similarly stained. 
Two are stained faintly with the basic dye ; the remaining ones 
are stained with the acid dye indicative of a chemical change. 
Magnification 270. 



-.iHSf 







Fig. 11. JJetz eil: -j' i: ^ urea. Tliere is euiniiKMu-iiig cliroiufU >ly.s)s 
of varying degree. The Nissl granules are not so closely packed 
together as in normal cells. The nucleus is larger and clearer 
than norxn|iL Magnification 350. 



HISTOLOGICAL CHANGES IN SHELL SHOCK 45 

similar to that described by Crile in the case of " a soldier 
who had suffered from hunger, thirst, and loss of sleep; 
had made the extraordinary forced march of 180 miles 
from Mons to the Marne ; in the midst of that great battle 
was wounded by a shell; lay for hours waiting for 
help, and died from exhaustion soon after reaching the 
ambulance." 

There are certain facts in the histological examination 
which we may correlate with what we know of the general 
symptoms of shell-shock neurasthenia with which this 
soldier suffered, viz. tremors and fatigability which were 
present before the final collapse. Can we associate these 
two general symptoms with any histological condition of 
the nervous system ? Most of the motor cells of the 
spinal cord and stem of the brain showed a fair number 
of normal Nissl granules, there was therefore no evidence 
of exhaustion. Likewise, the large Betz cells {vide Fig. 14). 
The cells which uniformly showed a marked change in 
absence of Nissl granules, and in many cases stained with 
acidophil eosin instead of the basophil blue dye, were the 
large cells of Purkinje of the cerebellum. This change I 
have now found in all three cases, so that in all probability 
it is not a fortuitous condition. If there is exhaustion of 
the cells of Purkinje it may be presumed that as the cere- 
bellum is essentially an organ of reinforcement of muscular 
action, the tremors and fatigability may be due to lack 
of this kinetic reinforcement. The maniacal excitement 
in this case may be associated with the pia-arachnoid 
haemorrhages, the engorgement of the veins and the com- 
parative empty condition of the arterioles and capillaries 
of the cortex. These vascular conditions maybe associated 
with the weak action of the heart and low blood pressure 
occurring in the initial stage. The maniacal excitement 
is not unlike the delirium tremens of chronic alcoholism 
in which the higher inhibitory cortical structures are 
poisoned by the drug. In this case haemorrhages into the 



46 WAR NEUROSES A'ND SHELL SHOCK 

sheath of the vessels of the interna] capsule were found, 
and also in the pons ; which may account for the existence 
of the plantar extensor response and fanning of the toes 
in the initial stage. Strabismus, diplopia and nystagmus 
may occasionally be found in the initial stage, and these 
conditions may be due to small haemorrhages in the stem 
of the brain; the effects of which soon pass off in the 
great majority of cases. The cause of sudden death in 
this case may be explained by the vascular congestion 
and haemorrhages in the medulla oblongata, and the con- 
dition of exhaustion of the cells of the vago-accessorius ^ 
nucleus. Had this patient lived it is highly probable he 
would have recovered from the maniacal condition in a 
few days to a few weeks, and any signs of organic disease 
of the nervous system would have passed off in a short 
time. The condition of emotivity would have remained 
for a long time, and perhaps he would never have been 
the same man again — any more than a man who has 
been doncussed by a severe blow on the head. The 
symptoms which would have persisted are those of neuras- 
thenia, viz. tremors, severe headache, insomnia, terrifying 
dreams, ready fatigability by mental and bodily efforts, 
asthenopia, amnesia, especially loss of memory for recent 
events, rapid acting heart (possibly signs of affection of 
the endocrine glands in the form of a mild degree of 
hyperthyroidism). 

CASE II 

Clinical Notes 
Captain Duffield reported that information obtained from the 
medical ofTicer attached to the unit in which the man, a gunner 
in the Royal Garrison Artillery, was serving, was to the effect 
that he was sitting in a corrugated iron hut, fifty yards from 
some boxes of cordite cartridges, when a shell landed and 

^ It has been pointed out to me that the cells of the vago-accessorius 
at the level of the calamus scriptorius are too low down to be related to 
cardiac functions. Unfortunately the medulla at a higher level had 
been damaged. 



ANATOMICAL CHANGES IN SHELL SHOCK 47 

exploded them. The man became miconscious at once; his 
breathing was stertorous ; his body showed no signs of wounds. 
On the same day he was removed to a dressing station and 
thence to a casualty clearing station ; in the evening of that 
day he died. The medical officer there stated that the patient 
was absolutely unconscious, and could not be roused. His 
breathing was stertorous and slow; the pupils were equal and 
reacted to light; knee-jerks were difficult to obtain. He died 
shortly afterwards, and at the post-mortem examination the 
brain was removed, placed in spirit, and dispatched. 

Macroscopical Appearance of Brain 

On the upper surface of the cerebellum, the temporo-sphenoidal 
and left orbital lobes there was superficial haemorrhage. On 
cutting up the pons, oval patches were seen as large as one- 
sixth by one-quarter inch; whether this is simple staining of 
haemorrhage cannot be determined until a microscopical ex- 
amination has been made. Portions of the mesencephalon 
and pons were taken for microscopical examination; the 
medulla oblongata was not sent. 

Microscopical Examination 

Post-parietal. — Meninges : Marked congestion of all vessels 
of the surface of the brain with extravasation of blood into the 
soft membrances. In the grey matter of the cortex the perivas- 
cular spaces are dilated throughout, and the vessels, capillaries, 
veins, and arteries are for the most part empty. In the white 
matter no punctate haemorrhages are seen; there is marked 
dilatation of the perivascular spaces ; the capillaries, veins, 
and arteries aref empty. In the cortex there is dilatation of 
the perineuronal spaces, which in many instances may be 
seen communicating with the perivascular spaces {vide Fig. 8). 
Ascending Frontal. — Stained with thionin. The large pyra- 
midal cells show pretty marked chromatolysis without swelling 
of cell; some of the Betz cells show commencing breaking up 
of the tigroid bodies ; smaller pyramidal cells show undoubted 
swelling of nucleus and loss of pyramidal shape (very similar to 
that observed in experimental anaemia in animals) with varying 
degrees of chromatolysis. As a rule, the smaller the cell, the 
more marked is the change. 

Left Orbital Lobe. — On the under surface there is extensive 
extravasation of blood into the substance of the brain and on the 
surface, and there is very marked dilatation of the perivascular 
spaces everywhere. The cortex is in a measure destroyed in 
one place ; it shows very marked dilatation of perineuronal as 
well as perivascular spaces, which intercommunicate. 



48 WAR NEUROSES AND SHELL SHOCK 

Corpus Callosum. — There is much congestion of vessels, and 
many have ruptured into the sheath, forming long, irregular 
branching, haemorrhagic extravasations, but no sign of puncti- 
form haemorrhage. Betz cells seem rather shrunken than 
swollen in the ascending frontal. 

Left Temporal Lobe. — Shows remarkable dilatation of the peri- 
vascular spaces, and there is a big globular haemorrhage, and 
much haemorrhage into the substance of the brain. 

It will be noted that in this case the man was sitting 
in a corrugated iron hut fifty yards from the explosion. 
His body showed no signs of wounds. Being in a closed 
space, the man got the full effect of the aerial compression 
and decompression, and if the statement can be relied 
upon that there were no wounds on the body, we must 
assume that the forces of compression and decompression 
generated by the explosion were sufficient to cause the 
changes observed in the brain. But it is quite possible 
he may have been blown up and suffered with physical 
concussion without having wounds but not without con- 
tusions, for we know what terrific forces are generated by 
the detonation of large quantities of these high explosives. 

CASE III 

Another brain was sent to me by Lieut. -Col. Elliott in which 
the corpus callosum was torn at its posterior extremity pre- 
sumably by concussion, for there was evidence of bruising of 
the scalp and haemorrhage without any fracture being discovered 
post mortem. The man was brought down in the ambulance 
train unconscious, and died the same day. No notes accom- 
panied him, therefore it was only presumption that he had 
been blown up and that the falx cerebri had cut through the 
corpus callosum. There was subpial lucmorrhage pretty general 
over the surface of the whole brain, and in the fourth ventricle 
there was a thin film of blood. On cutting up the brain it was 
noticed that there were punctiform haemorrhages in the sub- 
cortical white matter, and especially were these numerous and 
eoalescent in the centrum ovale near the region of laceration 
of the corpus callosum. Microsopic examination exhibited 
great venous congestion in the pia-arachnoid with rupture and 
haemorrhagic extravasation. The blood in many places had 
penetrated the brain substance both in the cortex and the stem 



ANATOMICAL CHANGES IN SHELL SHOCK 49 

of the brain, also, though to a less degree, in the cerebellum. 
The subcortical white matter showed numbers of punctiform 
haemorrhages, and in the centre of these haemorrhages were 
found vessels blocked by a hyaline thrombus such as is found 
in gas poisoning, so that it is possible the man suffered from 
concussion and gas poisoning. The vessels in the subcortical 
white matter, in the internal capsule, the pons and the 
medulla were congested, and many of the smaller of them 
had undergone rupture with escape of the corpuscles into the 
perivascular sheath. So that in this respect the lesion re- 
sembled the condition found in Cases I and II, but differed 
in the fact that there were punctiform haemorrhages. The 
post-mortem examination was made so soon after death as 
to preclude the possibility of the changes to be described in 
the cells being due to any fortuitous cause. They wdre remark- 
able, and pointed either to a toxic condition and hyperthermia 
or possibly exhaustion. 

The sections stained with Nissl or Leishman stain showed 
an absence of Nissl granules. The cytoplasm examined with 
an oil-immersion lens showed only a fine dust incrusting the 
fibrillary network. They have not swollen nor lost their con- 
tour. The nucleus appears large and clear. With Leishman 
stain the nucleolus is stained purple or pink, instead of blue. 
The intranuclear network has lost its bright-blue coloration, 
and appears, like the cytoplasm of the body of the cell and 
the dendrons, to be stained a dull purple colour. These changes, 
together with the hyaline thrombosis of the subcortical vessels 
in the centre of the punctate haemorrhages, point to some other 
agent than the mechanical concussion, for they were not 
present in Cases I and II of known shell shock. Moreover 
(as in Case IV, p. 51, which I described in my Lettsomian 
lectures), the vessels showed in places definite signs of acute 
inflammation in the form of numbers of polymorpho-nuclear 
leucocytes and lymphocytes around and in the perivascular 
sheath. 

It must therefore be presumed that in all probability, in 
addition to the physical effects of the explosion causing rupture 
of vessels, there was a toxic agent which had caused the uniform 
bio-chemical changes found in all the ganglion cells of the central 
nervous system and of the larger neurons, particularly the 
cells of Purkinje of the cerebellum. 




Fig. 15. — Section through the whole brain, Case IV, shell shock without 
visible injury, 1 inch external to the mesial surface. Punctiform 
haemorrhages are seen in the white matter whicli have coalesced in 
the corpus callosiun, corona radiata, and in the white matter of the 
hemisphere generally. 



Fig. 16.— Verti- 
cal section through 
the left hemisphere 
in the frontal re- 
gion, s howing 
coalescence of 
haemorrhages in 
the corpus callo- 
sum, internal cap- 
sule, and lenticular 
nucleus. 




,.w-^ 



Fig. 17. — Vertical 
section through hemi- 
sphere, Case 1, showing 
a wedge-shaped area of 
coalesced haemorrhages 
upon the under surface 
of the anterior part of 
the occipital lobe. This 
is the only region where 
tlie haemorrhages had 
coalesced so as to form 
in the grey matter an 
area visible to the 
naked eye, but through- 
out the cortex, as in 
the case of CO poison- 
ing, there are capillary 

haemorrhages ; at this situation the haemorrhage has ruptured the grey 
matter and produced a subpial extravasation. The microscopic appear- 
ances of the haemorrhages are seen in Fig. 18. 




^ 




ANATOMICAL CHANGES IN SHELL SHOCK 51 



CASE IV 

Fatal Case of Shell Shock and Contusion ; Histological 
Changes in the Central Nervous System 

Specimen received from Captain W. E. M. Armstrong, 
R.A.M.C., No. 7 Mobile Laboratory, B.E.F. Sent on from 
No. 1 Mobile Laboratory. No. 8 on Captain Armstrong's list. 
Brain of man (Figs. 15, 16. 17) admitted unconscious with 
history of having been butied by shell blowing in parapet. 
Remained stertorous for two days and died. 

Post-mortem. — There is no wound of any kind on his body or 
head, and no visceral lesion. His ankle on one side was badly 
" sprained," but there were no fractures. The skull was un- 
fractured, and no fracture of the base could be found. Brain 
shows multiple capillary htrmorrhage and (some slight) subpial 
extravasation. No other particulars. 

Histological Examination of the Brain. — Throughout the 
white matter of the centrum ovale, and especially in the 
corpus callosum, internal capsule (Figs. 15, 16, 17) and cerebral 
peduncles, are multiple punctate haemorrhages {vide Fig. 18). 
They also occur in the subcortical white matter and in the basal 
ganglia. In many places these himnorrhages have coalesced into 
large areas, and in the parieto-occipital region there is a diffuse 
purple staining of the white matter around the hjT^morrhagic area. 
Microscopic examination shows isolated capillary haemorrhages 
in the grey matter; in the medulla there are only congested 
vessels, but no haemorrhages. This appearance to the naked 
eye corresponds to that which I have described in CO poisoning. 
Sections of the brain were cut after hardening and embedding 
in celloidin and stained with haematoxylin eosin, van Gieson, 
and by Nissl method. The same microscopic appearances 
were observed as those seen in coal gas (CO) poisoning, only 
the haemorrhages were more extensive. The case of coal- 
gas jioisoning where the patient lived four days, instead of 
48 hours, as in this case, showed in the cells of the medulla 
(Fig. 19) a marked chromatolysis with swollen clear eccentric 
nucleus, similar to the change observed in experimental 
auffimia of animals. It is most marked in the cells of the 
vagus nucleus, but more or less general throughout. In the 
cortex many of the Betz cells show a very marked chroma- 
tolysis, swelling of the cell and eccentric nucleus, while others 
in the immediate neighbourhood may possess a fairly normal 
amount of basophile Nissl granules {vide Fig. 19). Besides the 
above-mentioned changes many of the small vessels ex- 
hibited inflammatory changes. But all stages may be met 



52 



WAR NEUROSES AND SHELL SHOCK 



Fig. 18.— Photo- 
micrograph of SPt- 
tion of corpus 
callosvim from case 
of shell shock, 
showing the capil- 
1 a r y p vi n c t a t c 
haemorrhages. In 
several cases a 
small white area 
of brain tissues is 
seen, in the centre 
of which is a small 
artery or vein. 
Magnification 20 
diameters. 




'■"^fUs^^ 



Fio. 19.— Section 
of medulla oblon- 
gata from case of 
shell shock with 
burial, stained by 
Nissl method, 
showing the swol- 
len cells of the 
nucleus ambigvius. 
Observe the en- 
larged, clear, eccen- 
tric nucleus ; the 
surroimding cyto- 
plasm shows an 
absence of Nissl 
granules. In noi 
a single cell is tlic 
nucleus seen in the 
centre as it should 
be. Magnification 
450. 





>>• c? 








( 




4^ 




- 





ANATOMICAL CHANGES IN SHELL SHOCK 53 

Avith. These photomicrographs show the above-mentioned 
changes which correspond with those due to deoxygenation 
of the blood in CO poisoning or in experimental ana;mia by 
ligation of all four arteries. As I find the most extensive 
hsrmorrhages, but no evidence of sudden death and swelling up 
of the axons as in the case of spinal concussion, I have come 
to the conclusion that it is possible this man was rendered 
unconscious by shell shock, and that while buried he was 
poisoned with gas. 




Fig. 20. — Photomicrograph of a Betz cell, showing swelling of the cell ; 
disappearance of the Nissl bodies. The nucleus is clear, large, and 
eccentric ; in the immediate neighbourhood are cells in which this 
change has not occurred. It is possible that haemorrhage has rup- 
tured the axon of this particular cell. Magnification 800.^ 

Spinal Concussion 

A number of cases of spinal concussion have come under 
my notice. Some have been under my care and have so 
far recovered that they could be discharged from the 
hospital. I will briefly relate one case in which I diagnosed 
spinal commotion and haemorrhage. 



Private C— 
5, 1917. He had had two years' service, and was six months 



8th Seaforths, age 20, was admitted January 



54 WAR NEUROSES AND SHELL SHOCK 

under fire. On December 22nd he was in a dug-out when an 
8"6 in. shell exploded on the dug-out, blowing the back of it in. 
He was standing up at the time, and he remained in the u})right 
position, never lost consciousness and was got out in a few 
minutes. He was sent to HavTC and then on to the Maudsley 
hospital. Catheterised three days at Havre; upon admission 
he had incontinence of ftrces and urine. 

There was no evidence of bruising nor any tender spot over 
the spine ; there was no evidence of paralysis of face or tongue. 
There was a marked weakness of the muscles of both arms; 
the paresis was more marked on the right than the left. He 
wag able to lift his arm above the head, and to turn over in 
bed. The most marked loss of power was in the hands. There 
was only slight ])ower of movement in the legs. No muscular 
wasting, no marked flabbiness. Patellar and ankle clonus on 
both sides. Plantar extensor response on both sides. Wrist 
tap and triceps jerk both easily obtained. Pupils normal. No 
ocular paralysis or nystagmus. Hearing and sight unaffected, 
also taste and smell. He complained of no headache, tremors, 
dreams, sweating or of anxiety. There was no evidence of 
neurasthenic emotivity. When asked how he felt the invari- 
able reply was, " All reet." In about a month he had recovered 
power over his bladder and bowels. The movement in the 
arms and legs had increased in power, and he was able to j^ut 
his feet on the ground. Two months later he was able to 
stand and walk when supported by two men. Three months 
after admission he was able to walk with the aid of a stick and 
was sent home. 



CASE V 

Spinal Concussion from Burial ; no Gross Injury, no Fracture 
and no Dislocation of Vertebra'. Macroscopic Ila-morrhage 
in Cervical Cord ; Characteristic Microscopic Changes. 
Paralysis of both Arms, Legs, and Intercostals, Ancestliesia ; 
Consciousness retained until Death. 

Lance-Corporal A , admitted to No. 17 Casualty Clearing 

Station on September 11, 1915, suffering from paralysis. 
Captain W. J. Adie, R.A.M.C. (S.R.), writes : — On the morning 
of the 10th instant, during a heavy bombardment of one of the 
trenches, this man was buried in his dug-out under timber, 
sandbags, and earth. He was excavated within five minutes, 
and it was noted that he had lost the use of his arms and legs. 
He was conscious and rational. He did not complain of pain. 
I was not called to see the man as he had no wound, and there 



ANATOMICAL CHANGES IN SHELL SHOCK 55 

were many serious cases needing attention. In the morning he 
arrived at the dressing station just as the ambulance was 
leaving and was put straight in. I regret that I did not see 
him. The patient was sent down on the early morning of the 
11th to the 18th Field Ambulance, and told the medical officer 
that he had shell shock. His pulse was then 40 and temperature 
97° F. He complained of pains in his head and back. On the 
same morning later he was admitted to the casualty clearing 
station, where Lieutenant Dew observed rigidity of his legs 
and noticed that he was in a state of " cerebral irritability," 
calling out, " Let me alone." I (Captain Adie) was asked to 
see him on that day, but he could not be found by the sergeant- 
major, so, having several other cases to see, I did not see him 
until the next day. 

On the morning of September 12th he was seen at 11 a.m. by 
Captain Dennis and Captain Stokes. He was lying flat ; his 
abdomen was rigid ; he showed total flaccid palsy of both legs 
and arms. A feeble extensor response (easily fatigable) was 
obtained from the right sole, no response from the left. The 
cremasteric reflex was absent on the right side; was present, 
but easily fatigable, on the left side. The abdominal and 
patellar reflexes were absent. The sphincters were not para- 
lysed. His breathing was shallow and laboured. The ribs 
were motionless. Sensation was completely absent on the 
limbs and on the trunk up to apparently the second cervical 
level, but his mental condition was too bad for the results to be 
very reliable. Heat and cold were indistinguishable. 

At 12.30 p.m. I saw the patient. The orderly reported to me 
that the patient was continually asking to have his position 
shifted. I saw him propped up, when his abdomen was flaccid. 
He was obviously near death, and it was difficult to get much 
from him. He protruded his tongue normally at request. He 
complained of feeling sick and of being unable to get his breath ; 
" I am tied up," he said. Speech normal. Total intercostal 
palsy. Pulse full, slow, 54. Complete flaccid palsy and 
anaesthesia of all limbs. Plantar response : left leg, normal ; 
right leg, faint flexion of proximal phalanges. No difficulty 
in swallowing. No incontinence or retention of urine or faeces. 
Unable to get any history from him. He died at 1.30 p.m. 

Post-mortem examination at 2.15 p.m. by Captain Stokes. 
Slight but not definite mobility of the fourth cervical vertebra. 
No dislocation or fracture of vertebrae found. No external 
wound. A good deal of intravertebral haemorrhage while, 
getting out the cord ( ? normal bleeding from venous plexus). 
No clot in the vertebral canal. Some haemorrhage within the 
upper part of theca, but this probably got in from the cut end. 



56 WAR NEUROSES AND SHELL SHOCK 

Haemorrhages within cord in mid-cervical region and possibly 
in upper dorsal region. Cord preserved in 5 per cent, formol. 
Description of Cord by Dr. Mott (September 17, 1915). — There 
are visible haemorrhages in upper cervical region, extending 
about 1 inch on external surface of dura mater. On reflect- 
ing dura a subpial haemorrhage can be seen ^ inch in length, 
I inch in breadth, over posterior surface of the cervical 
cord beneath the pia-arachnoid. The central canal at 
the level of the third cervical and about the level of the middle 
of subpial haemorrhage contains blood about the size of a large 
pin head. This can be traced down to the upper part of the 
fourth cervical, and at the level of the lower part of the fourth 
cervical segment there is an obvious extension of the haemor- 
rhage into the right anterior horn. At the level of the fifth 
and upper part of the sixth cervical the haemorrhage apparently 
extends throughout the whole of the grey matter. At the 
seventh cervical there is an obvious change in the grey matter, 
but the haemorrhage is nmch less extensive. At the eighth 
cervical there is an apparent change in the whole of the grey 
matter, also in the first dorsal. The outline of grey matter 
becomes more distinct about the third dorsal, but throughout 
the dorsal region the naked-eye appearance suggests the jiro- 
bability of some change in the grey matter. Even in the 
lumbo-sacral region the grey matter does not appear quite 
normal in its outline. Subsequent microscopic examination of 
sections showed that the changes seen in the outline of the 
grey matter above described were due to some congestive 
oedema. 

Histological Examination of the Spinal Cord. — The spinal cord 
was hardened in formol and cut after embedding in celloidin. 
Sections were cut and stained by van Gieson, Weigert Pal, and 
Nissl methods. The appearances presented corresponded with 
those described by Colonel Gordon Holmes in gunshot injiu-y 
of the spine without penetration of the dura mater but causing 
concussion ofthe spinal cord. (FtdeFigs. 21, 22,23.24, 25,26. 27, 
with descriptive text). It is presumed, as there was no visible 
sign of injury, that the man was struck on the neck by a sand- 
bag, for he was partially buried. The fact that the subpial 
haemorrhage was over the posterior column, and the damage 
affected especially the posterior column and the grey matter, 
suggests that a pressure wave of the cerebro-spinal fluid was 
set up by the concussion, and the grey and white matter lying 
between the fluid in the central canal and the subarachnoid 
received the full force of the shock. Had it been a segment 
higher, instant death from complete destruction of the phrenic 



ANATOMICAL CHANGES IN SHELL SHOCK 57 

nucleus would have occurred. As it is, the microscopic ex- 
amination shows that a partial destruction of " nucleus 
diaphragmaticus " took place {vide Fig. 25). 

Dr. Sano, who has made a special study of the origin 
of the phrenic nucleus (diaphragmaticus), has been kind 
enough to look at these sections and indicate exactly the 
group from which the nerve arises : it is the median group 




Fig. 21. — Section of the fifth cervical section of spinal cord of Case 5, 
spinal concussion withovit evidence of external injury. Observe the 
appearances of the grey matter and the posterior column, and the 
antero-lateral column of one side as compared with Figs. 22 and 23. 
This is at the seat of conciission. (In Figs. 21, 22 and 23, Weigert-Pal 
staining was employed.) 

of the anterior horn. These cells are entirely destroyed 
in the fourth and fifth segment, but are present in the 
third. They show, however, as compared with the other 
ganglion cells in the anterior horn at this level, some 
chromatolysis, as if under the stress of increased activity 
the basophile kinetoplasm had undergone some disintegra- 
tion without corresponding reintegration. The posterior 
column at the seat of the concussion presents a diffuse 
sieve-like vacuolation of the myelin fibres, such as has 
been described by Gordon Holmes, One sees also the 



58 WAR NEUROSES AND SHELL SHOCK 



.^Km 








^QH 






p^ 



Fig. 22. — Section of the fmirth cervical segment; observe the cavitation 
of the grey matter starting from the central canal and extending into 
the anterior horn and down the posterior horn of one side. It is only 
in these two fourth and fifth segments that gross macroscopic changes 
can be observed. 




Fig. 23. — Section of the third cervical segment, 
changes fire observable. 



No gross macroscopic 



ANATOMICAL CHANGES IN SHELL SHOCK 59 







Fig. 24. — Longitudinal section of periphery of posterior column at the 
level of the fifth cervical segment ; the dark stained swollen axons 
are seen. Magnification 200. 




Fig. 25. — Section of third cervical segment of spinal cord case of con- 
cussion, stained by Nissl method, showing the median group of 
anterior horn cells corresponding to the nucleus diaphragmaticus, 
and they show a certain amount of perinuclear chromatolysis, but 
all the cells exhibit the Nissl granules. Even at the seat of con- 
cussion, the fourth segment, an external group of cells remain show- 
ing Nissl granules. Concussion, therefore, does not destroy the Nissl 
granules. Probably the cells of the nucleus diaphragmaticus show a 
certain amount of chromatolysis because they were continually dis- 
charging impulses along the phrenic nerves, and the few cells that 
were left of the nucleus had therefore mych piore work to do. 
Magnification 300. 



60 



WAR NEUROSES AND SHELL SHOCK 









^P ^zBviMBs^r^^^^K^^^^^^^ 




fcHi^*^»WQIfcB*r*iB^^Bi^^^^^^^^^^^^^B 


^^^s^^B^ 


Bfffc^yy? jL^^^^^^^^^^^^^^^^B 


^^^^k 
^^M 


ppflBBu*^' M^^^BUWI^^^^^^^B 



Fig. 26. — Section of periphery of posterior column at the level of the 
fifth cervical segment. Vacuolation of myelin sheaths and many 
swollen axons are seen. Magnification 300. Van Gieson staining. 







Fio. 27. — ^Myelinat<^d projection fibres in the motor cortex. Three twisted 
axis-cylinders are seen ; they are not swollen. Magnification 300. 



ANATOMICAL CHANGES IN SHELL SHOCK 61 

enormously swollen axis-cylinders {vide Fig. 26). This also 
is seen well in longitudinal sections {vide Fig. 24). The 
shock may have been so great as to have killed the axo- 
plasm ; for, as Leonard Hill, in a letter to me, says : "A 
water pressure of between 300 and 400 atmospheres kills 
all protoplasm (excepting deep-sea fishes). Water enters 
into the muscle and swells it and turns it opaque. There 
are curious fractures produced in the muscle fibres. The 
myelin of nerve fibres is broken up by the water entering 
into these." Then he goes to on say : " In the case of 
a high-velocity bullet striking the spine, it seems possible 
that the cerebro-spinal fluid beneath the struck part may 
be instantly compressed and act as a solid body trans- 
mitting the blow to the cord. There cannot be time for 
the fluid to be displaced. There is, anyway, a water- 
pressure limit beyond which protoplasmic activity is 
destroyed, and I imagine bullets must produce this pres- 
sure, but I very much doubt whether air waves produced 
by shell-bursts can reach to such pressures as 300-400 
atmospheres." It is quite possible that a sandbag hurled 
against the neck could produce this effect without pro- 
ducing visible injury. This sieve-like character of the 
white matter and the large swollen axis-cylinders are only 
found in the posterior column from the fourth to the 
seventh segment inclusive. There are haemorrhages in 
the white matter of the posterior column as low as the 
seventh cervical. Below this segment no haemorrhages 
are seen in the white matter, but congestion and small 
capillary haemorrhages are found throughout the grey 
matter of the spinal cord. Since only about forty-eight 
hours elapsed between the concussion and death, there 
was no time for degenerative appearances of the white 
matter to occur; there was apparently a sudden destruc- 
tion of a portion of the axons in the posterior column. 
No physical or chemical changes have occurred in their 
continuity above and below the seat of concussion, which 



62 WAR NEUROSES AND SHELL SHOCK 

certainly would be shown in the long fibres of Goll's column, 
where a large number of these greatly swollen axons and 
vacuolated myelin sheaths are seen. Although there are 
haemorrhages at the seat of the lesion in the posterior 
column, the greatest amount of haemorrhage is in the 
more vascular grey matter, and, as the photomicrographs 
show, the destructive disintegration is very marked at 
the level of the fourth and fifth cervical {vide Figs. 21, 22) ; 
it is also seen to a less degree in the sixth and seventh. 
Shock, no doubt, interfered with the autonomic activity 
of the muscles of respiration below the lesion; it is 
remarkable that it did not produce a shock effect on 
the bulbo-spinal nuclei above. This shows how well pro- 
tected they are from shock, also that a transverse lesion 
of the cord produces a shock effect down the efferent 
projection fibres and not up the afferents. It is note- 
worthy that this undoubted case of spinal concussion 
without visible injury accords in the histological changes 
with those described by Gordon Holmes. The blood con- 
tained in the area of haemorrhage in the posterior column 
would soon be absorbed and give rise to the cavitation 
observed by Holmes in this region. I have seen a number 
of cases of spinal concussion caused by a bullet wound of 
the spine without penetration of the theca vertebralis in 
which the signs and symptoms pointed to spinal con- 
cussion. I was able to investigate a case which pointed 
to spinal commotion rather than concussion. I am 
indebted to my late assistant, Captain Moodie, R.A.M.C., 
for the following notes and material. 

Private A , 16th Middlesex. Died July 8, 1916. This 

man was badly wounded on July 1, 1916, during the early 
advance on the Somme. There was a superficial graze pro- 
bably caused by shrapnel or a fragment of shell over the spine 
of the left scapula and a small in-and-out wound over the right 
gluteal region. This wound was about two inches long and 
superficial. It was clean, and the muscles were not involved. 
He had had tetanus antitoxin (quantity unknown). His 



ANATOMICAL CHANGES IN CONCUSSION 63 

mental condition was fairly clear, although somewhat marked 
by his halting speech and extreme somnolence. He was, of 
course, much fatigued, and had suffered from lack of food. He 
had complete paralysis of the legs and abdominal muscles and 
the left side of the face. There was marked loss of power in 
both arms. There was a complete anaesthesia from the level 
of the umbilicus downwards, atony of the bladder with overflow 
incontinence and loss of control of the rectum. 

The pulse varied between 80 and 90 per minute, but was of 
weak tension ; there was no albumin in the urine. He merely 
became weaker and eventually coma preceded death on July 8, 
1916, without additional symptoms having presented them- 
selves. Post mortem : Complete examination was made and 
nothing to account for death was found. 

William Moodie, 
Captain R.A.M.C, 
" O.C. 17 Mobile Laboratory. 



Microscopic Examination of Portions of the 
Spinal Cord 

A portion of the spinal cord extending from the eighth 
dorsal to the fourth lumbar segment was sent to me for 
examination by my former assistant, Captain Moodie. 
The material arrived in good condition in formol solution. 
Portions were blocked in paraffin, and sections of five 
microns were cut and stained by van Gieson, Nissl, and 
Leishman stains ; the last named yielded the best results. 

The eighth, tenth, twelfth dorsal, first and second lumbar 
segments were examined; similar appearances, although 
the changes varied in intensity and degree, were observed 
in all the sections. Briefly they were as follows : On the 
surface of the spinal cord blood corpuscles were seen 
adhering — evidence that the cerebro-spinal fluid had con- 
tained blood during life. The veins upon the surface of 
the spinal cord were everywhere congested ; the arteries 
and capillaries as a rule were empty. In places the veins 
could be seen ruptured, and in some sections intraradicular 
hcemorrhage was observed. In the substance of the spinal 
cord itself were numerous minute haemorrhages, varying 



64 WAR NEUROSES AND SHELL SHOCK 



in size from a pin's head, and visible to the naked eye, to 
a pin's point, invisible except by aid of the microscope. 

The haemorrhages are seen especially in situations where 
the surromiding tissue offers least support; consequently 
they are found in the grey matter of the anterior horns, 
but especially at the base of the posterior horn near the 
central canal {vide Fig. 29). 

Frequently small veins are observable both in the grey 
and white matter which have ruptured, and numbers of 




Fig. 28. — Medium -sized anterior horn cells in first Iiunbar segment ; a 
microscopic haemorrhage is seen near ; the Nissl granules have almost 
disappeared in the ceils, and the staining is diffused and uniform 
without the displacement of the nucleus. Magnification 330. 

the escaped red corpuscles are seen in the perivascular 
sheath. 

There are distinct changes in the anterior cornual cells 
of varying intensity. There is perivascular chromatolysis, 
and not infrequently there is some swelling of the cell and 
eccentrically placed nucleus {vide Fig. 30). These changes do 
not seem to bear a direct relationship to the haemorrhages ; 
it is probable that the finding of these wide-spread capillary 
and venous ruptures with blood extravasation is important 
in showing the violence of the commotion to which the 
delicate fibrils, forming the neuronic synapses in the grey 
matter, have been subjected. Mechanical compression by 
the escaped blood corpuscles probably plays only a minor 



ANATOMICAL CHANGES IN CONCUSSION 65 




«t^ ,»■»•.• ' s ■; s* 



^■"*;" '-'^^'pi- 



Fig. 29.— -Hajmorrliage, the size of a small pin's head, at the base of the 
posterior horn ; the tissues aronnd are fractured and retracted, but this 
may be in part due to the action of the fixing fluid. Magnification 185. 





.# 


1 


I:- 


w 


e 


1 


l^** 






/^ 


* ''t%^ 


'■ <^ 






^•*:X 



Fig. 30. — Two large anterior cornual cells from the third lumbar segment 
showing fairly well marked perivascular chromatolysis ; the nucleus in 
one is eccentric and the nucleolus cannot be seen. Magnification 360. 
F 



66 WAR NEUROSES AND SHELL SHOCK 

part in producing the loss of function. Had an examina- 
tion of the cervical cord, of the bulb, and of the pons been 
made, no doubt similar changes would have been found to 
account for the symptoms noted. The anaesthesia below 
the level of the umbilicus likewise may be accounted for 
by the damage to the grey matter especially noted at the 
base of the posterior horns. 

We do not know what happened to this man, but the 
shrapnel wounds and the condition of paraplegia, together 
with the histological microscopic findings in the spinal 
cord, strongly support the view that a large shell burst 
near by, wounding him and causing spinal commotion 
but without injury of the spine. He may have been blown 
up in the air and thrown violently on the ground, but this 
seems unlikely, as the notes state that his mental condition 
was unimpaired and there was no visible injury of the 
spine ; consequently the most plausible explanation of 
the cause of the pathological condition of the spinal cord 
is commotion. No cause for death could be found except 
shock. 

Very probably had the rest of the nervous system been 
examined I should have found a condition of things similar 
to the other cases of shell shock that became comatose 
and died, viz. marked congestion of the veins, subpial 
haemorrhages, ruptured vessels with collapsed and empty 
arterioles, capillaries and venules associated with dilatation 
of the perivascular sheaths and chromatolytic changes of 
the ganglion cells indicative of exhaustion. But I have 
found this same condition of vessels and ganglion cells in 
a patient that became comatose and died of shock caused 
by very extensive burns. It seems probable that emo- 
tional shock produces sudden loss of consciousness by its 
effect upon the vaso-motor nervous system causing sudden 
lowering of blood pressure and cortical anaemia. But 
emotional shock may be followed by more or less perma- 
nent effects, and especially when combined with the 



FRENCH AND GERMAN NEUROLOGISTS 67 

physical effects of shell shock the vaso-motor derange- 
ment may persist and the patient may become comatose 
and die. If this does not happen the patient may show 
on recovery of consciousness various signs of cortical 
anasmia with its attendant neuronic exhaustion and dis- 
sociation, viz. headache, dizziness, tremors, delirium, am- 
nesia, inability to concentrate, mental confusion, auto- 
matic wandering, and so on. 

Opinions of French and German Neurologists 
regarding Shell Shock by Windage 

Many discussions have taken place by French and 
German neurologists regarding the question of organic 
changes occurring in the central nervous system as a result 
of vent du projectile or windage. According to Leri, a 
true commotion appears only to be produced at a proximal 
distance of some ten metres from great projectiles. The 
finding of groups of men dead in the last attitude of life, 
in closed spaces such as the German concrete dug-outs, 
and the proven fact that enormous forces of compression 
and decompression are generated by the detonation of 
high explosives in great shells, aerial torpedoes, and 
mines have lent support to the view that mere proximity 
to the explosion is sufficient to cause organic changes 
in the brain and spinal cord by the atmospheric com- 
pression and decompression ; altogether apart from actual 
concussion caused by violent contact with solid materials, 
such as sandbags or the earth forming the walls of a 
dug-out, which may at the same time cause burial or 
partial burial, unattended by visible evidence of injury of 
the body sufficient to account for symptoms of cerebral 
or spinal concussion. The patient is rendered unconscious 
and his mind is a blank concerning what happened in 
a true case of "commotio cerebri"; consequently he is 
unable to say whether he had or had not been concussed 



68 WAR NEUROSES AND SHELL SHOCK 

by tlie sand or earth. In the two cases under consider- 
ation there was no history of burial. 

Undoubtedly the vast majority of non-fatal cases of 
shell shock are more emotional in origin than commo- 
tional, and occur especially in subjects of an inborn neurotic 
or neuropathic temperament ; but the two conditions may 
be associated. Both Leri and Meige emphasize the fact 
that commotional symptoms are not influenced by psycho- 
therapy. They also point to the fact that in cases where 
organic changes have occurred the cerebro-spinal fluid 
withdrawn by lumbar puncture exhibits macroscopic or 
microscopic evidence of blood indicating that haemorrhage 
had occurred. 

In Case I Captain Stokes noted at the post-mortem 
examination that the fluid was blood-stained, and the 
microscopic findings of ruptured vessels explain this. 

Leri states that the subjects of commotion are generally 
depressed, asthenic, aboulic, and often more or less con- 
fused mentally; they present almost constantly, even in 
light cases, pronounced disturbances of voltaic vertigo. 
They often suffer with bleeding from the ear, or nasal or 
vesical haemorrhage. Roussy and I'Hermitte admit that 
in rare cases vent du projectile may cause organic changes. 

Robert Bing gives a review of the German opinions upon 
nervous accidents determined by the near explosion of a 
projectile. He points out thaf Vogt and Gaupp, who have 
occupied themselves with Granat Kontusion (bomb con- 
tusion), are far from accepting the exclusive psychogenic 
role in the development of this syndrome. Gaupp insists 
particularly upon the relations which exist between the 
initial symptoms presented by those patients and the 
rapid succession of atmospheric compression and decom- 
pression which takes place at the moment of the bursting 
of the projectile. The existence of labyrinthine lesions, 
almost regular in this class of case, is in support of this 
opinion (Schultze and Meyer). 



FRENCH AND GERMAN NEUROLOGISTS 69 

In von Sarbo's numerous publications upon the subject 
there is a tendency to regard these cases from a uniform 
point of view. For him the general mass of observations 
do not permit the diagnosis of organic changes in the 
usual sense of the word, nor that of psycho-neurosis. He 
believes microstructural alterations occur, but they are 
not equivalent to the molecular changes of Charcot. He 
includes in the microstructural changes meningeal cedema, 
microscopic haemorrhages, transitory paralysis of vessel 
walls, and contusion of the nuclei and centres. In the 
initial period these lesions may give rise to some discrete 
symptoms of organic disease ; later they are manifested 
by functional physical and psychical symptoms. Bing 
remarks that the pseudo-neurasthenia of arteriosclerosis 
supports this view. It is interesting to note that the 
haemorrhages into the perivascular sheaths of vessels 
observed in Case I resemble in some respects those seen 
in arteriosclerosis. 

Oppenheim's view of traumatic neuroses had few sup- 
porters at the Congress at Munich. 

Aschaffenburg examined soldiers in Flanders who had 
been exposed to shell fire in the trenches but had escaped 
unwounded and were apparently well. The examination 
took place in most cases within twenty-four hours after 
leaving the trenches. Of seventy-four men so examined, 
sixty-seven showed unmistakable signs of localised organic 
lesions of the nervous system, although not as a rule of a 
serious nature. A second examination a week later showed 
that some, but not all, of these phenomena had disappeared. 
Here were cases, therefore, in which an organic basis was 
present but no traumatic neuroses had developed. Aschaf- 
fenburg gives the result of his experience in these words : — 

" In assuming organic change as one of the consequences 
of shell explosion I do not thereby agree with Oppenheim 
that the nervous symptoms are to be attributed to these 
changes. On the contrary, it is to be noted that the most 



70 WAR NEUROSES AND SHELL SHOCK 

exaggerated hysterical cases which develop after exposure 
to shell firing are the ones which exhibit organic symptoms 
least of all." 

Experiments upon Animals 

Bearing upon this question of commotion I will refer 
to an interesting article by A. Mairet and G. Durante, on 
the " Commotional Syndrome," which was published in 
the Presse Medicale, June 15, 1917. They have experi- 
mented upon rabbits by means of powerful explosives in 
order to try and find out what happens to soldiers in the 
trenches. 

A charge of melinite or chedite placed at 1-50 metres, 
then at 1 metre, was successively raised from 125 grammes 
to 1 kilogramme. Of twelve animals used five died spon- 
taneously, respectively in five minutes, one hour, one day, 
eight days and thirteen days after. The others, after a 
momentary unconsciousness with acceleration of respira- 
tion and temporary excitement, sometimes rapidly re- 
covered and were killed, with the result that no signs of 
local lesions were present. Histological examination in all 
the animals that died showed early lesions consisting of 
more or less extensive islands of pulmonary apoplexy, 
caused by rupture of alveolar capillaries. In most cases 
haemorrhages and suffusions of blood were found on the 
surface of the spinal cord, in the roots between their 
emergence from the cord and at their conjugation; also 
limited ruptures of small vessels in the grey matter of the 
cortex and of the bulb, causing a blood effusion into the 
perivascular lymphatic sheath. 

More rarely perivascular suffusion of the radiate vessels 
of the medulla oblongata and of small vessels behind the 
ependyma was observed. The nerve cells were healthy. 
Vascular changes were found in the anterior horn and 
spinal ganglia only in two rabbits, and haemorrhages in 
the kidney were found in one animal. 



EFFECTS OF WINDAGE ON EYE AND EAR 71 

The haemorrhages especially occur from vessels which 
are badly supported by surrounding tissues, the blood then 
escapes into the perivascular lymph sheath which does 
not offer any support. The haemorrhages are minute, and 
are diffused, and this fact speaks in favour of a sudden 
rupture of the wall caused by the decompression which 
suddenly follows on the wave of compression. 

These changes observed by Mairet and Durante are very 
similar to those which I have described in the cases 
examined. Professor Marinesco has examined material 
obtained from animals exposed by Major Crile to the 
forces generated by the detonation of high explosives, and 
has observed similar changes to those above described. 

It will be noted that in Case I there was pulmonary 
haemorrhage found at the autopsy. 

The Effects of Windage (Vent du Projectile) upon 
♦ the Eye and Ear 

The majority of the cases of blindness resulting from 
individuals being in the proximity of an explosion of a 
shell are due to emotional rather than commotional shock. 
But cases have been recorded of changes in the fundus 
following shell shock, and a brief reference will now be 
made to these. 

In opening a discussion at the Ophthalmological Society, 
Ormond stated that few war lesions are of greater interest 
than those cases that have been collectively termed con- 
cussion bhndness; that is, a condition in which a soldier 
is rendered unconscious by proximity to the explosion 
of shells, bombs, aerial torpedoes, and other projectiles 
charged with high explosives, and when he regains con- 
sciousness finds that he is unable to see. Definite organic 
injuries may or may not be sustained by the eye. 

A major in the artillery was sent to me for blindness in 
the left eye ; he gave the following history : He was in 



72 WAR NEUROSES AND SHELL SHOCK 

a dug-out and a shell came through the roof and buried 
him. He was unconscious for three days. When he 
recovered consciousness, on June 8th, he was blind; he 
had some trivial wounds of the head and a good deal of 
blood came from the left ear. On July 1st he recovered 
sight in his right eye, but two months later he was still 
blind in the left eye ; even a bright light appeared " as a 
brown blanket." There was blepharospasm of this eye, 
and sometimes the eye was quite closed. The hearing was 
perfect. The fundi were normal. There was no evidence 
of any atrophy, therefore no evidence of haemorrhage 
around the nerve, which might have been suspected from 
the fact of his statement that blood came from the ear. 
The pupils reacted normally, and Mr. Treacher Collins, who 
saw the case for me, confirmed my opinion that it was 
functional. 

Captain Ormond, at a discussion held at the Ophthal- 
mological Society, described eleven, cases out of eighty 
with lesions which he attributed to " windage," but Captain 
Cruise, although he was ready to admit that cases might 
occur, doubted whether such a high percentage as Captain 
Ormond's could be regarded as reliable. 

Mr. Treacher Collins has described the case of a soldier 
who suffered from rupture of the choroid, attributed to 
the explosion of a shell near him. Also Mr. A. L. White- 
head said that a short time previously he had seen a case 
of "commotio retinae" within an hour of the accident. 

The general consensus of opinion was that vent du pro- 
jectile may produce retinal and choroidal lesions, but the 
instances are rare, and we can never be certain that there 
was no physical concussion in some of the cases that were 
not seen soon after the injury occurred ; for, as a rule, 
the man by losing consciousness and by virtue of an an- 
terograde and retrograde amnesia is unable to tell what 
happened. 

jEmil Grosz affirms that " detachment of the retina or 



EFFECTS OF WINDAGE ON EYE AND EAR 73 

rupture of the choroid may occur in cases in which the 
bullet passes at a relatively considerable distance." 

In cases of explosion, the air pressure alone may be 
responsible for such lesions as choroidal rupture or opacity 
of the lens; cataracts due to this cause resorb spon- 
taneously. 

Kinneir Wilson, in discussing the subject of Concussion 
Injuries of the Visual Apparatus, was of the opinion that 
" certain symptoms usually held to be functional in type 
may be the expression of a direct visual concussion, un- 
doubtedly an organic condition. These symptoms are 
concentric constriction of the visual fields, and the occur- 
rence of helicoid or spiral fields with certain tests." 

Mairie and Chaletin have described two cases where the 
visual fields were constricted. In these two cases there 
was a grave trauma of the occipital region, followed by 
cortical blindness. They regarded the general blindness 
as due either to commotion or compression. In each case 
the blindness persisted and was followed by macular 
vision. Wilson remarks that the restricted fields are clinic- 
ally indistinguishable from the fields met with in hysteria. 

Lister and Holmes describe a case in which there was 
limitation of the fields. Major Hurst in a letter to The 
Lancet, November 17th, 1917, is convinced that both 
narrow and spiral fields of vision are invariably the result 
of unconscious suggestion on the part of the observer. 

For the present, it appears to be a reasonable conten- 
tion that, in certain cases without permanent visual defect 
of the accepted organic type of hemianopia or scotoma, 
contracture of the fields and helicoid or spiral fields may 
be the expression of an organic change, the basis of which 
is a violent " commotio cerebri," or a concussion amounting 
to contusion of the visual cortex or some part of it, not 
more closely to be specified, or of the subcortical visual 
projection system. 



74 WAR NEUROSES AND SHELL SHOCK 

The Ear 

The cases of " windage " affecting the delicate structures 
of the eye are rare ; the same cannot be said of the ear, 
for deafness of one or both ears and vestibular symptoms 
are of frequent occurrence. Rupture of the tympanum and 
hsemorrhage into the middle ear are not at all uncommon. 
It may, however, be noted that a good many cases of deaf- 
ness are due to wax damped against the tympanum, to 
blocking of the Eustachian tube, and, in numbers of 
instances, the deafness has been due to aggravation of 
pre-existing middle and internal ear disease. I have seen 
a case of shell shock in which the haemorrhage into the 
middle ear was associated with and may have caused 
peripheral facial nerve paralysis. 

Capt. Gordon Wilson's results and observations are of 
great interest in respect to the relative frequency of ear 
affection. Of two hundred cases exhibiting nerve symp- 
toms ascribed to the forces generated by high explosives, 
which he saw at the 3rd Canadian Casualty Clearing 
Station, and at the 3rd Canadian Stationary Hospital — 
fifty complained of deafness of varying degree. Of these 
fifty, seventeen showed demonstrable signs of injury to 
the internal ear traceable to the explosive forces; that is, 
8-5 per cent. Of the remaining thirty-three, deafness 
had been temporary and no objective signs of disturbance 
of equilibrium were observable. The persistent defect of 
hearing was due in some to chronic middle-ear inflam- 
mation, in others to blocking by wax of the auditory 
meatus or to some other cause. 

Of the seventeen cases, seven had symptoms of nerve 
deafness without perforation of the tympanic membrane ; 
ten had deafness with signs of recent perforation ; six had 
definite middle-ear trouble previous to the concussion ; of 
the other eleven with no previous history of ear trouble, 
six had recent perforation ; twelve complained of vertigo and 



EFFECTS OF HIGH EXPLOSIVES ON EAR 75 

had observable signs due to it ; the others had complaints 
or symptoms pointing to disturbances of equilibrium. 

From these observations, and also from an extensive 
experience at the West Cliff Canadian Eye and Ear Hospital 
in which he had under observation a hundred cases of injury 
to the internal ear and its central connections from high ex- 
plosives, Capt. Gordon Wilson has formulated the following 
conclusions upon the effects of high explosives on the ear : — 

1. Exposure to high explosives may produce rupture of 
the membrana tympani. This rupture may occur at any 
part of the membrana. It varies in size, and two perfora- 
tions are occasionally seen. Small perforations are most 
frequent, but there may be a large perforation, and in one 
of these the malleus was driven back. 

2. The rupture in the membrana tympani tends, in most 
cases, to spontaneous closure. Its non-closure is usually 
due to its large size, or middle-ear suppuration following 
the rupture. Appropriate treatment hastens healing and 
diminishes the risk of suppuration. Adhesion of the 
malleus to the internal wall of the middle ear is frequent. 

3. Concussion of the internal ear with nerve deafness 
and equilibrium disturbances occurs with or without rup- 
ture. In many cases the concussion passes off with slight 
damage to hearing, though equilibrium disturbances may 
persist for a considerable period. 

4. The concussion may pass off leaving an injured nerve 
mechanism demonstrable by : (a) nerve deafness of a 
varying^ degree; (b) defect of equilibrium. 

5. The treatment of recent perforated membrane which 
gives most satisfactory results aims at leaving the blood 
clot over the perforation intact. The following has been 
found satisfactory : A plug of cotton is placed in the 
meatus and the lobe of the ear is cleaned and dried. The 
plug is removed, and then the outer part of the external 
meatus is cleaned by pledgets of cotton dipped in hydrogen 
peroxide. The meatus is then dried and washed with 
pledgets dipped in alcohol and again dried. A piece of 
sterile cotton is then placed in the ear. 

6. All the cases ought to be kept in bed for at least ten 
days to allow effects of the concussion to subside. 

7. The detonation of high explosives may cause a definite 



76 WAR NEUROSES AND SHELL SHOCK 

injury to the car and its central connections. The diag- 
nosis requires consideral)Ie experience. A considerable 
proportion of the cases seen with deafness following ex- 
posure to high explosives had no sure definite trauma 
demonstrable, and the deafness ])reseut was accounted 
for by some other cause. Speedy recognition of those so 
injured by high explosives, with treatment, means more 
rapid recovery of hearing, diminution of the subjective 
symptoms of vertigo, so apt to persist, and subsequent 
usefulness. In view of these facts an otologist of experi- 
ence ought to be available at appropriate centres, 

8. Apart from such injuries, there w(>re frequently seen 
cases of deafness or ear disease in which removal to the 
base was unnecessary, e.g., wax in the ear, furunculosis in 
the canal or slight serous discharge from old perforations ; 
and cases where delay in treatment involved in transporta- 
tion to the base has aggravated the disease and delayed the 
recovery, e.g., acute middle-ear disease. In such cases an 
otologist ought to be available. 

Voltaic Vertigo 

The French lay stress upon the frcciucjicy with wliich 
disturbances oi" voltaic vertigo occur as a result of com- 
motion provoked by the forces generated by the detonation 
of explosives without causing visil)le injmy; it is really 
labyrinthine shock. Henri P'rangais diagnosed cerebral 
commotion by explosion in cases where there was no 
external injury, but subjective sensations, toncther with 
hypertension and hyperalbuminosis of the ecrebro-spinal 
fluid. Two electrodes of two eentinietics (h'ameter arc 
employed, and one is placed on each mastoid. 

In the normal state the head inehius to the side of the 
anode with three to live milliamperes. In the patients so 
examined suffering with commotion, the head is inclined 
towards the same side, whether the j)ositive or the negative 
pole be applied to either mastoid. According to Leri 
it requires fifteen milliamperes to cause vertigo in cases 
of shell shock. According to Fran9ais, voltaic vertigo 
demonstrates in the subject of commotion the existence 



VERTIGO AND SHELL SHOCK 77 

of vestibular disturbances in a great number of cases. 
In those cases where voltaic vertigo is normal and no 
objective symptoms can be found, commotion may be 
regarded as deprived of grave symptoms and the patients 
can be returned to their depots after a short rest. Out of 
thirty-two patients thus diagnosed and examined twenty- 
five showed disturbances of voltaic vertigo. Fran9ais 
further considers that focal encephalic lesions may arise, 
and he describes a case of hemiplegia in a non-syphilitic 
subject of shell shock, with all the signs of Babinski 
present. There was no cardiac disease. 

Jacob made an examination of voltaic vertigo in 115 
subjects ; he gives the following table of comparative 
results of trephined and commotional cases. 





Trephined Cases. 


Commotion. 


Normal Vertigo 


. 10 . 


. 2 


Pure Resistance 


. 13 . 


. 8 


Abnormal Formula . 
Without Resistance . 


• 1 29 . 


. 13 


Abnormal with resistance 


. 25 . 


. 14 



Another method which he employed of testing laby- 
rinthine excitation was to make the subject take a stick 
in his two hands and with head bent down turn round 
three times, firstly in the same direction as the movement 
of the hands of a watch, then three times in the opposite 
direction. There is a positive excitation of the left laby- 
rinth, a tendency to fall towards the right in the former, 
and in the latter there is a positive excitation of the right 
labyrinth and a tendency to fall to the left in the normal 
state. 

^ Capt. Golla, from a series of interesting experiments with the rotat- 
ing chair on spatial perception, formulates the conclusion that in vertigo 
there is consciousness of displacement of the ordinary balance between 
the vestibular sensation and the muscular sense. It was when there was 
a discrepancy between the two sensations that one became conscious of 
something being wrong with the position of the head. When there was a 
destructive lesion of the vestibule the person behaved in a different way ; 
he was unbalanced, and his sensations were different from what they 
would be were both vestibules acting. 



78 WAR NEUROSES AND SHELL SHOCK 

Consecutive Mental Phenomena of Shock 

Temporary irresponsibility : A man who is suffering 
from shell shock may become maniacal and suffer with 
delusions or hallucinations, causing him to be dangerous 
to himself or his comrades ; he may suffer with mental 
depression and become suicidal. He may be dazed and 
behave like an automaton and wander away from his 
post. This is not an infrequent cause of a court martial 
for desertion. 

Case of Temporary Irresponsible Action. 

November 16th, 1917. — The patient denies that there are any 
neuropathic tendencies in his family. 

He is 49 years of age, attended school from 5 to 13 years old, 
reaching the 4th Standard. He had no serious illness. After 
school he worked in a wool factory for one year and then took 
up wood working. He is now a wood turner, averaging 
earnings over £2 per week. He is married and has six living 
children and four dead. He has been temperate regarding 
alcohol, averaging about two glasses per week. 

He joined March 25th, 1915, and went to France January 
1916. On the 18th July he was struck on the forehead with a 
piece of shrapnel, was knocked about six feet and unconscious 
for three hours. He was sent to England, and for one year 
was in and out of hospitals, complaining of paroxysmal head- 
aches of variable duration from a few hours to several days. 
He is quite positive that there were no convulsive attacks. He 
returned to France June or July 1917 and was assigned to a 
Labour Battalion, where he was exposed to shell fire. A 
German 'plane came over dropping bombs, and the patient says 
he lost his head. He challenged an officer and threatened to 
shoot him, and later was discovered pointing a rifle at an officer. 
He was confined to his quarters, and the patient was surprised 
the next day when told of what he had done. He returned to 
England about October 15th, 1917, and for two weeks was at 
Eastleigh and a fortnight at the Maudsley. 

Now he has no headaches and there have been no convulsive 
attacks. He keeps to himself and does not associate much with 
the other men, but works about the ward and reads the news- 
papers. He has a fair idea of the progress of the war, but 
seems to have a poor memory, as shown by the difficulty he has 
in recalling the birthdays of his children. He is clear about 



MENTAL CONFUSION AND SHOCK 79 

present time, gives the day and date correctly, although he 
has not acquired the names of people here. Physically he has 
exaggerated knee-jerks, slight tremor of the hands, but the 
tongue and eyelids are steady. There is general loss of muscular 
strength, he tires easily and does not feel cheerful. The X-ray 
plates show nothing abnormal. 

The officer's account of the assault is to the effect that the 
patient challenged him at night with a loaded rifle and without 
learning his identity apologised. Later the officer was told 
by a bombardier that he found the patient taking aim at this 
officer, who was standing at the door of his tent. 

It is the officer's opinion that the patient had a delusion that 
he was to patrol the camp and look for spies. 



Mental Confusion with Hallucinatory Delirium 

Mental confusion with hallucinatory delirium (day- 
dreams) is not an uncommon sequel of " shock," which 
may be due not only to " commotion," but to an even 
greater degree to " emotion." In this condition the 
patient not only suffers with terrifying dreams at night, but 
he has terrifying day-dreams of the terrible experiences and 
sights he has witnessed (mrfe pp. 126, 127) ; he may be deaf, 
aphonic, mute, or both deaf and mute. " There is no art 
to find the mind's complexion in the face," even if he 
cannot speak, for the expression denotes horror or great 
anxiety ; there is motor agitation, sometimes a convulsive 
crisis occurs, and tremors are always present. His speech, 
if he is able to speak, is usually either tremulous, hesitant, 
syllabic or stammering. He has occasionally suicidal and 
homicidal impulses owing to hallucinations, as shown by 
the following case. 

Shell Shock : Retrograde and Anterograde Amnesia, recollecting 
only the Noise and Flash of the Explosion ; Wandering ; 
Seizures of Intense Fright, as if he had Terrifying 
Hallucinations inciting him to defend himself by asking 
and feeling for his Revolver. 

Lieut. G recollects nothing that happened in the past, 

not even going to France, nor the Colonel, nor the places he was 



80 WAR NEUROSES AND SHELL SHOCK 

stationed at, but by looking at a map he recognised that it was 
Albert. He does not recollect being admitted to the hospital 
at Le Treport, but recovered his senses there, and he recollects 
everything since. 

When he was admitted to hospital he stated that he had a 
recollection of a great noise and a vivid flash. He sees blood 
during the day. He has terrifying dreams of the whole roof 
bursting in on him. The other night he said he felt he wished 
to kill another man in the room. 

He remembered that he had a thrashing at school, but of 
where the school was he has no recollection. 

He still complains of headache, made worse by attempts to 
remember. He says that he had trench boots on when he was 
admitted to the C.C.S., and also that there was mud on his 
hair. 

After admission to the Maudsley hospital, a patrol found him 
wandering and said that he was quite natural in his manner, 
but he could not remember what his name was. He refused to 
go to bed when brought back, but we put him to bed. He 
was continually asking and feeling for his revolver. He was 
not drunk nor was he violent, but he had, from time to time, 
seizures of intense fright, and he glared about him feeling at 
the same time for his revolver, shouting out, " Here they come, 
boys; shoot the devils." He also saw again in his imagination 
a scene in the C.C.S., that no doubt he had witnessed, for he 
mentioned the name of a corporal in the R.A.M.C., and said, 
" Don't let his head fall, if you do he will die." These terrifying 
day-dreams lasted for some time and were associated with 
homicidal tendencies. 



Mental Confusion and Hebetude 

After a variable period of unconsciousness following 
" shock " the soldier may recover. If he is not dumb it 
will be found that his mind is in a state of confusion; 
there is both anterograde and retrograde amnesia. He has 
little or no idea of time or place, and his powers of recogni- 
tion and comprehension are greatly impaired. He may 
be deaf or mute or a deaf-mute ; it may be difficult therefore 
to ascertain what his mental condition is by conversation ; 
or, unlike simple pithiatic mutism, he may be unable to 
write. The condition of his mind is reflected, however, 



MENTAL CONFUSION AND SHOCK 81 

in his face, for he has a dazed, stupid, mask-Hke, mindless 
expression. He probably assumes an anergic, crouched 
or curled-up posture, but he may wander about in an 
automatic-like way. 

In all these conditions consecutive to commotional 
shock there is severe headache and vertigo; the deep 
reflexes are exaggerated, and in some cases there are signs 
of hyperthyroidism, rapid action of the heart, hyperidrosis 
and aero-cyanosis. 

The " shock," not necessarily commotional, may cause 
such an effect upon consciousness that for days, weeks or 
months the patient may remain in a state of anergic 
stupor; there is a complete emotional indifference, not 
unlike some cases of dementia praecox. The patient sits 
in a crouched attitude indifferent to his surroundings, or 
lies in bed curled up and makes no response to questions ; 
the expression is mindless, the hands cold, blue and 
sweating, the pulse feeble; only the vegetative centres of 
his brain seem to be working normally. He can be fed 
and swallows the food given him. He may for a time be 
indifferent to the calls of nature. Later he may be roused 
with difficulty, and when he begins to recover, speech may 
be limited to a few words. His replies to questions denote 
a deep degree of amnesia; possibly he can only utter a 
few inarticulate sounds or words. The speech may be 
tremulous, hesitant, staccato, or there may be perseveration 
of words and syllables. All the outward mental manifesta- 
tions of the patient, his attitude and expression, his language 
and his conduct are those of a child. There is, in fact, a 
mental regression to the stage of early childhood. This 
condition may be regarded as an alteration of the per- 
sonality characterised by a state of amnesic delirium 
founded upon a basis of mental confusion. I have seen 
four cases in which both the words uttered and the sen- 
tences framed resembled those of an infant ; e. g., one 
patient, a Canadian, who made a complete recovery, when 



82 WAR NEUROSES AND SHELL SHOCK 

asked how he did to-day for some time replied, " Me 
bettah," the tone and modulation of the voice being quite 
infantile. Another case was that of a New Zcalander, 
who, when sat up to be fed, scrambled forward with both 
his hands like a dog when digging a hole. We afterwards 
learnt that this man had been buried for some time, and I 
came to the conclusion that this was a perseveration of 
a purposive movement connected with the instinct of 
self-preservation. When these cases recover consciousness 
they often complain of terrifying dreams of horrifying 
experiences witnessed prior to the shock; sometimes they 
dream of the sound and flash of the exploding shells. 
The facial expression denotes anxiety, fear, and sometimes 
horror. The cases I am about to relate no doubt were 
psychogenic as well as commotional in origin. Probably 
the former factor was the more important of the two. 

Shell Shock followed by Condition of Complete Amyiesia, 
Mask-like and Mindless Expression and Infantile Vocabulary 
and Mode of Utterance. 

Personal History. — His associates say that he was a " decent 
chap," a teetotaller and non-smoker before he joined up. 
He began to smoke while in the army. He started to keep a 
diary and called it an account of his journey and health in 
France. From this diary it is learned that he joined the army 
in June 1916 and arrived in France on October 12th and went 
into the trenches in October. 

October SOth, 1916. — He refers to the bombardment and says 
his nerves suffered a severe shaking and that he had headache. 
He was in the trenches only 28 hours and complained of rheu- 
matism and reported sick. He was in hospitals from Novem- 
ber 21st, 1916, to May 19th, 1917, when he again went to 
France. After rejoining his regiment they were in rest quarters 
and moving until July 4th, 1917, when he left for the trenches. 

The medical record shows that he was in a " nose " trench 
and was blown up on July 5th, after having been in the trenches 
part of two days. 

Attitude and Manner. — The attitude is distinctly childlike. 
He stands in an uncertain attitude, feet slightly spread, body 
bent forward slightly, head on one side and arms hanging limply. 
He is bashful and self-conscious and reaches for the nurse. 



MENTAL CONFUSION AND SHOCK 83 

much as a child looks for his mother. The facial expression is 
blank and the lines of expression are smoothed. He is not 
apathetic or " shut in," and is distinctly in contact with his 
environment. He notices children's voices in the street out- 
side, and is amused by a passing street piano. He is distinctly 
curious about what happens. 

He comes when called, but does not obey commands to 
open mouth, close eyes, show tongue, and give hand. When 
addressed in simple language (" Soldier, show tongue ") he 
can imitate the motion made by the examiner. He does not 
dress himself, he eats with his fingers, although clean in his 
habits. When he wants to go to the rear he asks for the key 
by making a motion as unlocking a door. He spends much 
time playing with picture cards and roughly blocking with 
coloured pencils the outlines of animals and flowers. He 
copies letters beginning where one ordinarily finishes, but the 
result is fairly good. In copying London he makes the letters 
all except the o's, for which he leaves spaces. He cannot be 
induced to attempt the o's. He holds the pencil as a table 
knife is usually held. He has special places for his various 
articles, and keeps certain pictures apart from others. Emotion- 
ally he is curious and interested and not at all apathetic. He 
plays with pictures and papers, moving them about and 
handling them, and looks longingly at his wife's picture. He 
occasionally cries when looking at his wife's picture and traces 
her face with a forefinger. 

His vocabulary is limited to the words " me," " man," 
" soldier," " dallas," and " yes." He does not name a knife, 
pencil or penny, but says " yes," when asked to name them. 
When shown a group of photographs containing nurses and 
patients he was asked if a nurse was " man." He said " yes," 
to all of the women, but called the men soldiers. He had a 
small basket with pin-cushions representing apple, plum, 
and strawberry, but does not point to the article when asked 
to do so. 

November 2Uh, 1917. — About two weeks after this was written 
the patient was visited by his wife. He showed a decided 
change in his condition shortly after. His facial expression 
was better and he became more interested. Now he is quite 
natural in his demeanour, associates freely with the other 
patients, converses freely and no longer acts like a child. He 
says that he can remember nothing about the period between 
July 4th and his wife's visit, does not recall the winter or his 
admission to the hospital. He recalls perfectly everything 
that takes place about him now, is correctly orientated and 
remembers trivial incidents of yesterday. He has slight 



84 WAR NEUROSES AND SHELL SHOCK 

tremor of hands, tongue and eyelids, but no disorder of gait or 
weakness of the arms. He dreams nearly every night and 
awakes with a start. He reads and can write, but does not 
sing, whereas before his sickness he was quite fond of singing. 



Shock in Relation to Loss of Memory 

Amnesia may be confounded with Unconsciousness 

Before the introduction of the Army Form W. 3436 a 
very great difficulty in the complete investigation of cases 
of sheir shock arose from the fact that few or no notes, as 
a general rule, accompanied the patients ; one had therefore 
to rely upon the statements made by the patient himself, 
or perchance of a comrade, if he had no recollection of the 
events that happened. Those cases of shell shock, however, 
which were able to give satisfactory information of the 
events that preceded the shock (to tell you even that they 
could call to mind the sound of the shell coming, and see 
it, in the mind's eye, before it exploded), followed by a 
blank in the inemory of variable duration, are in all proba- 
bility not commotional, but emotional in origin. In the 
more severe cases, especially where there has been burial or 
physical concussion by a stone or a sandbag, or by falling 
heavily on the ground after being blown up in the air, 
there is a more or less complete retrograde amnesia of 
variable length of time. In a case of simple shell shock 
it is impossible to say whether the patient was unconscious 
during the whole period of time of which he has lost all 
recollection of the events that happened, or whether 
during the whole or a part of the time he was conscious, 
but, owing to the " commotio cerebri," the chain of per- 
ceptual experiences was not fixed. In the majority of 
cases shell shock affects only the higher cortical centres; 
in severe cases the vital centres, as in apoplexy, alone 
continue to function, or the patient is only in a dazed 
condition, and he may automatically perform complex 



LOSS OF MEMORY AND SHELL SHOCK 85 

sensori-motor purposive actions of which he has no recollec- 
tion whatever. Several cases of this kind have come under 
my notice, but I will describe only one of the most reliable, 
as it is a history obtained from an officer : — 

His company had dug themselves in in a wood ; he went 
out into the road to see if a convoy was coming, when a large 
shell burst near him. It was about two o'clock in the morning 
and quite dark; about 4.30 a.m. it was quite light, and he 
found himself being helped off a horse by two women who 
came out of a farm-house. He had no recollection of anything 
that happened between the bursting of the shell and this 
incident. It is interesting to note that it is possible for him 
to have inhaled noxious gases, for the single cigarette in a 
metal case that was in his breast pocket was yellow on one 
side, due, no doubt, to picric acid contained in the explosive. 

All degrees of effects on consciousness may be met with, 
from a slight temporary disturbance to complete uncon- 
sciousness with stertorous breathing continuing till death. 

The following is another case of amnesia which was 
complicated by choreiform movements. 

A young lieutenant was admitted under my care suffering 
with acute chorea. There was no rheumatic history; he had 
a bruise over the left forehead; he complained of terrifying 
dreams. He remembered nothing that happened hetween his 
arrival at Havre and his return to consciousness at the hospital 
in Boulogne except a vague notion of arms and legs flying in 
the air, of which he frequently dreamed. I ascertained that 
he had been at Hill 60, battle of Neuve Chapelle, and had been 
blown up by a shell and suffered with concussion. His brother 
had received a letter from him telling him that he was moving 
to the front, but he had no recollection of having written this 
letter. He could recall nothing that happened after his arrival 
at Havre. Reading the newspaper, he saw the word Bailleul ; 
he said he was familiar with the name as a place he had been 
at, but it was merely a word association, for he had no recollec- 
tion of the place nor of anything that happened there. Some 
of the terrifying dreams this patient had were based upon 
incongruous association of past experiences. Thus he was 
troubled especially by this dream : He and his company were 
charging up an inclined plane ; when they arrived at the top a 



86 WAR NEUROSES AND SHELL SHOCK 

gigantic Prussian sat down and swept them all back. The 
inclined plane was associated with the fact that he had seen a 
battleship launched prior to going to France. After playing 
billiards he dreamt that Prussians were pelting him with red- 
hot billiard balls. The terrifying dreams in this case persisted 
for months. But the only recollection he has of experiences 
during the period of anterograde and retrograde amnesia was 
of arms and legs flying in the air, of which he has a vague 
recollection. 

Memory and Recollection 

Memory is the storing away of perceptual experiences 
out of consciousness, and recollection is reviving by will 
. and association the images of those experiences in con- 
sciousness. Some of these patients after they have 
recovered from the shock and are convalescent are able to 
revive in consciousness the events which happened. A 
great psychic feature of " commotio cerebri " from shell 
shock is the resulting inability of the brain to exercise 
sustained attention on account of the mental fatigue which 
occurs, and rest is imposed by the feeling of weariness 
and various forms of headache or discomfort. Again, 
irresolution and indecision are a frequent result of shell 
shock, whether induced suddenly or after prolonged ex- 
posure to shell fire and the stress of trench warfare. This 
is a serious disability in officers and non-commissioned 
officers placed in positions of responsibility. The con- 
dition is often associated with loss of recollection of recent 
happenings, and this disability is a constant source of 
anxiety to the officer who is conscious of the possibility of 
his failure to execute orders. 

Shell Shock : no History accompanying this ; 'provisionally 
diagnosed Cerebrospinal Meningitis. Sent to England ; 
marked Amnesia, signs of Hyperthyroidism. Return of 
Memory and Account of being blown up by a Shell. Gradual 
subsidence of all Symptoms. 

Private P L , admitted to Maudsley Hospital 

October 19th, 1917. Went to France April 191T. 



LOSS OF MEMORY AND SHELL SHOCK 87 

October 20th, 1917. — Expression that of fear and dementia. 
Dilated pupils; isthmus of thyroid enlarged; v. Graefe sign; 
tremor of eyelids when closed; tremor of hands; jerks of legs 
and back. Inco-ordination in arms and legs — more so in 
legs. Epigastric, cremasteric and plantar reflexes normal. 
Knee-jerks exaggerated. Holds neck stiff with head slightly 
backward, but can bend it forward. Kernig's sign not obtained. 
Very nervous and easily frightened, and cries. A provisional 
diagnosis of cerebro-spinal meningitis had been made. There 
was, however, no rash and the cerebro-spinal fluid exhibited 
no evidence of meningitis by microscopic examination; nor 
could meningococci be cultivated. 

He is better to-day and states that he was fighting at Ypres, 
where he was shelled on the 31st July " in the push." He says 
that he was gassed once, but still " carried on." He described 
the gas (which was tear-gas) as smelling like pineapple. 

After recovering from shell shock he returned to the line. 
This time he heard the shells, but did not see the one that 
affected him, and did not know anything until he found himself 
in a hospital {vide Fig. 31). 

October 2Mh. — He feels better, but last night he was awakened 
by the orderly when he was dreaming. He was afraid he was 
going to die. His heart felt queer and he could not breathe. 
He felt that he could not move or help himself. 

His memory is poor as to recent and past events, and he is 
unable to do a simple sum. He cries when talking of his wife. 

November 1st, 1917. — Blood-pressure, recumbent 116 systolic, 
85 diastolic; pulse rate 96. Pulse pressure is low (31), and 
the sound is weak, difficult to determine the diastolic change; 
the throw of needle of instrument is also slightly less than 
normal. A suggestion of a positive Babinski of both sides 
(though probably negative). No Kernig sign or stiff neck. 
Pupils react slightly to light and accommodation, equally 
dilated. Von Graefe, Moebius, Stellwag signs positive. No 
anaesthesia made out, but general hypersesthesia. Heart sounds 
weak; apex beat not obtainable by palpation, and very weak 
sounds upon auscultation. 

Better, sleeps fairly well. Less forgotten and altogether 
less appearance of fear. Albumin in urine, no casts. 

November 29th, 1917. — He now remembers more of the 
experiences from the time he went out to France imtil he was 
shelled. When he was in the trench, the parapet was partly 
knocked down and he was partly buried by a shell which 
exploded twelve feet from him. He lost consciousness at the 
time of the explosion. He remembers nothing more until 
he came to the hospital, 



88 WAR NEUROSES AND SHELL SHOCK 




Fia. 31. 




Fig. 32. 



Fig. 33. 



PERIODIC AMNESIA AND SHELL SHOCK 89 

Physical examination. — Still well-marked von Graefe sign. 
Convergence poor. Pupils dilated. Thyroid palpable. Pulse 
80 per minute. Moderate coarse tremor of tongue and fingers. 
Much better. Has headaches. Dreams about the war; sees 
the Germans coming up with their helmets and grey uniforms. 
He thinks much of war experiences during waking hours ; 
always rather nervous [vide Fig. 32). 

November 29th, 1917.— The patient has not improved beyond 
a certain point, although he is now much better than on 
admission. He is being invalided. 

December SOth, 1917. — This patient has made a most extra- 
ordinary recovery. He is still very feeble in mind and body, 
but will i^robably still further improve with hospital treatment 
and should be kept in on that account. 

He was discharged at the end of January {vide Fig. 33). The 
thre? photographs show his condition at successive periods. 

Periodic Amnesia 

Lapses of memory lasting hours or days may occur in 
soldiers who have suffered with shell shock months or even 
years after it happened. Men who are in hospital or who 
have been discharged from hospital are subject to these 
lapses. Sometimes they are brought to the hospital by 
the police, who have found them wandering, unable to 
give any information which would lead to their identifica- 
tion. To take a typical case. A soldier, who had a gold 
stripe on his tunic showing that he had suffered with a 
battle casualty, was brought by the police to the hospital ; 
he could neither recollect his name nor his regiment; he 
did not know where he had come from nor where he was 
going to. He could comprehend and obey simple com- 
mands. He did not understand his own name when 
written down. He had a dazed appearance and exhibited 
the usual signs of hyperthyroidism. We subsequently 
found that he had suffered with severe shell shock. These 
lapses of memory are psychogenic, and are apt to be 
attended with serious consequences. I have not met with 
cases which have been dangerous to themselves or others, 
as sometimes happens in the automatism of epileptics. A 



90 WAR NEUROSES AND SHELL SHOCK 

sufferer with periodic amnesia is, however, liable to be 
taken up by the police and placed in the lunatic ward of an 
infirmary, if he has been discharged from the army; or 
if he has taken a little alcohol he might be charged with 
being drunk. 

Psychogenic amnesia may arise from other causes than 
*' commotio cerebri," as the following case shows. In fact, 
when we speak of shell shock causing periodic amnesia, it 
must be borne in mind that other factors, such as emotional 
shock, acquired emotivity, and especially a neuropathic 
predisposition, may be followed by periodic lapses of 
memory. 

An officer with distinguished service was brought into 
the 4th London General Hospital by the police on 
January 7, 1918. I saw him the next day; there was a 
great deal of mental confusion, he did not realise where he 
was, nor could he give any connected account of himself. 
His orientation in time and space was very deficient. 
There was no head wound or sign of injury. The next 
day he was able to give the following account of himself. 

In April 1917, trench fever; sent to Rest Station, Camoens, 
after two weeks returned to first line. On August 19th-20th, 
after the Lens attack and as a result of prolonged insomnia, 
he had two attacks of unconsciousness, lasting about four 
hours and eight hours respectively. No warning. He was by 
himself, and therefore does not know what happened. On 
November 8th, after Paeschendale, he was evacuated again 
with trench fever; he could not use his legs and had great 
pain at the back of his head, also difficulty in retaining water. 
Anglo-American Hospital at Vimereux, one week. Plymouth : 
remained there about four weeks ; recovered use of legs, but 
had pain in head and insomnia; no bad dreams. December 
13th he applied to return to Canada, and his request was 
granted. He was discharged upon three weeks' furlough; 
went to Lincolnshire and reported at the H.Q.M.B. January 
4th he was instructed to report at Whitley. On the 7th he 
reported at once by letter, and received permission from CO. 
to report to him on 7th or 8th, without kit. On Monday, 7th, 
he remembers inquiring about trains at Waterloo ; from thence 



MUSICAL MEMORY AND SHELL SHOCK 91 

onwards to admission to the 4th London General Hospital his 
memory is a blank. His mother suffers with neurasthenia. 
Father is eighty. He has four brothers and two sisters, who 
have no evidence of nervous or mental affection. Two brothers 
have been killed in France. He has no recollection of anything 
that happened during those three periods of amnesia. 

Another case was that of a man who had signs of con- 
tusions on the head resulting presumably from an accident, 
but his memory was a blank from the time he had left his 
friends to the next day after his admission to the hospital. 



Musical Memory in Relation to Shell Shock 

The musical memory usually returns earlier than other 
forms of memory. An interesting example is afforded 
by the following case. 

Private G was admitted under my care; his mind was 

a complete blank, and his condition was reflected in a dazed, 
mindless, mask-like expression. When asked where he lived, 

he said, " W " ; he did not know that it was in the West 

Riding. He did not know the address of his home, and when 
shown a letter from his father with the address on the top he 
did not recognise it or his father's handwriting. When shown 
a photograph of his home with a group of his father, mother, 
and three brothers and himself in front of it, he maintained 
the same wondering, dazed expression, and failed to recognise 
the nature of the picture. His father had heard from a com- 
rade that he had been buried by the explosion of a shell in the 
trench; he had been unconscious for some time and had lost 
his speech. We heard from his father that he was a good 

musician, and I said to him, " G , I hear you are a good 

musician," and I asked him if he could play the piano or sing; 
there was the same wondering, bewildered look, and he mut- 
tered something which was to the effect that he could not 
sing or play. Three days later I said, " Come, you can whistle 
' God Save the King.' " He took no notice, but upon pressing 
him, he looked up, a glint appeared in his eyes, and he said, 
"You start me." I whistled the first bar, he took it up, 
and whistled it admirably. I then asked him to whistle 
" Tipperary," but he could not do it till I started him, and 
the same with several other tunes, but once started he had ng 



92 WAR NEUROSES AND SHELL SHOCK 

difficulty, and I recognised from the admirable intonation that 
he was, as his father described him, an excellent nmsician. 
I could not, however, that day get him to start upon his own 
initiative any one of the tunes he had whistled. The next 
visit, three days later, I observed that his expression had 
changed. He smiled when I spoke to him, and I recognised 
clear evidence of a mind that had partly found itself. He 
could now whistle any of the tunes I had previously started 
him on by himself, when I called for the tunes. I then said, 
" Come along to the piano." He came, and I got him to sit 
down in front of it. I said, " Play." He looked at the 
instrument with a blank expression, as if he had never seen 
such a thing before, and I could not get him even to put his 
fingers on the keys. I then took one of his hands, and, hold- 
ing his forefinger, I made him play the melody of " Tipperary." 
He looked at me, and again I noticed a glint in the eye and a 
change of his blank expression indicatiAC of reminiscent asso- 
ciation. He put his other hand on the keys and played a few 
chords. I went away feeling confident that his musical talent 
would reveal itself. He played for half an hour M'hile I was in 
the ward without a single discord. The next time I came he was 
able to play any music set before him. His associative memory 
and recollection of music was in advance of other associative 
memories. Thus, eight months after he had recovered his 
musical memory, he had very imperfectly recovered his memory 
of elementary facts regarding his profession of a land sur- 
veyor — e. g., he could not tell me how many poles there were 
to a rood — ajid there was still a tendency to a vacant mindless 
expression and prolonged reaction time, as shown by delay 
and slowness in responding to questions as if there were a 
difficulty in linking up the necessary assoc'ations. 

This early return of the musical memory happened also 
in another severe case of amnesia, which I will briefly 
relate. 

This patient was admitted for *hell shock. He had almost 
a complete loss of recollection of all the incidents of his past 
life except some experiences of early life, such as where he 
went to school. His powers of recognition were limited to 
knowing his jmrents. He had a bewildered vacant expression 
and a slow reaction to questions; when interrogated his coun- 
tenance assumed a puzzled aspect as of one trying to recollect. 
His memory for recent events was absent, and persons whom 
he had frequently or daily seen he failed to recognise. After 



MUSICAL MEMORY AND SHELL SHOCK 93 

four months he had made but Httle improvement. . His memory 
of the past seemed to show the first signs of awakening in the 
associations of music. He recollected musicians that he had 
heard and songs that he had sung, although, as in the above 
case, he remembered nothing of his professional occupation. 
He said that while with his friends he had been asked to sing 
songs which they said he had sung before — that he did not 
recognise them at all when he saw them, that after they had 
been played to him two or three times he was afraid to begin, 
as he felt he did not know them, but that, once he started, 
" he seemed to know without remembering " and got through 
quite well. One song he managed after it had been played 
through only once (" I Hear You Calling Me "). I learnt from 
an officer who had been a school-fellow of this patient that he 
had suffered with a head injury in early life. This may have 
produced a locus minoris resistentice in his brain. 

Every state of consciousness which is habitually repeated 
leaves an organic impression on the brain, by virtue of 
which that same state may be reproduced more readily at 
any future time in response to a suggestion fitted to excite 
it. But it may be asked. Why shovild the memory of 
music be inore readily revived in consciousness than other 
experiences ? — for example, those connected with the pro- 
fessions of these two young men before they entered the 
army. I should explain it by the fact that there can be 
no doubt that cognitions, whether pleasurable or painful, 
are more deeply graven on the mind and more firmly fixed 
in associative memory when associated with intense feel- 
ing. Music, of all the arts, appeals most to the emotions, 
and probably this is the reason why countless men and 
women, even the uneducated, can recall the words of songs 
and hymns when they hear the first bar of the musical 
setting. 

Fixation and organisation of repeated experiences in 
the mind is shown in rnusic, for a song that has been sung 
a number of times only requires the first word or note for 
it to be continued to the finish without any effort of con- 
sciousness, the last note or word uttered serving as the 
appropriate stimulus of the next; as in an instinct we 



94 WAR NEUROSES AND SHELL SHOCK 

have what is termed a chain reflex. This was strikingly 
exempHfied in a soldier under my care who suffered with 
motor asphasia and right hemiplegia in consequence of a 
bullet wound of the brain. 

The bullet entered the left side of the head and passed 
through the left fronto-central region of the br^n and through 
the right orbit, destroying the eye; in its passage also it must 
have cut through the left optic nerve or tract, for he was 
totally blind. This poor fellow was very cheerful and com- 
prehended all that was said to him; thus, by feeling my tunic 
sleeve he recognised my rank, for when asked if I was a cap- 
tain he expressed negation by " oot,". colonel also by " oot," 
meaning "no," and major by "ah.' He obeyed all ccm- 
mands. Now, curiously enough, although he was able to 
express judgments only by " ah " and " oot," which corre- 
spond to Yes and No, he was able to sing several songs through 
without difficulty provided the first word or bar of music was 
given. Thus, I stood beside him and hummed " 'Tis a long 
way," and immediately he started the well-known chorus of 
" Tipperary," winding up with "Are we downhearted? — 
No ! " I then said, " Say Tipperary, Tom." He replied, 
" Oot," and he was unable to utter any of the words. It 
must be concluded either that the song had been repeated so 
often as to have become organised in both halves of the brain 
or in subcortical lower centres. We know also that in amnesia 
rhymes are recalled very easily, especially if they have been 
learnt in early life. A month later, when I saw him, he was 
able to walk and speak. Thus, given a half-crown, he felt it, 
then tried the rim for milling on his teeth, and said, " Two 
shilling bit." When asked again, he corrected it with " Half- 
crown." Given a penny, he tested it in the same way, and 
the unpleasant taste left in his mouth caused him to throw it 
down with all the signs of disgust, saying at the same time 
" Copper." 

Hysterical Speech Defects 

Various forms of speech defects are common; they are 
mutism, aphonia, stammering, stuttering, and verbal repe- 
tition. The most frequent speech defect is mutism. About 
one in twenty of those admitted with a history of shock 
due to high explosives, and having no visible signs of 



HYSTERICAL SPEECH DEFECTS 95 

injury, suffer with mutism, but are, nevertheless, quite 
able, as a general rule, to write a lucid account of their 
experiences. Most of the men so afflicted are unable to 
whisper or produce any audible sound; thus there is no 
sound when they laugh. They are unable to whistle or 
to cough, and in severe cases there is difficulty in putting 
out the tongue, and, in one case, of swallowing. The 
pharyngeal reflex is lost. Whereas mutism is common 
among soldiers and non-commissioned officers, it is com- 
paratively very rare in officers. Stammering, stuttering 
and verbal repetition is not infrequently met with in 
officers, and in many of these the history shows that they 
had these speech defects in early life or in pre-war times ; 
in some it was merely an exaggeration of a previous similar 
speech defect. The following two very severe cases of 
shell shock with mutism, which occurred in May 1915, 
may be cited, for two reasons : first, owing to the severity 
and persistence of the symptoms, I thought the case was 
not wholly hysterical, but due in part to commotional 
effects on the central nervous system ; second, in the light 
of further experience, I felt confident these cases were 
hysterical, and could have been cured in the early stages 
by physio-psychic therapy. 

^^ Severe Shell Shock" without Visible Injury except Wound of 
Wrist, Unconscious Three Days, terrifying Eaperiences and 
Dreams, marked Aspect of 2 error, Mutism, Weakness and 
Inco- ordination of Upper Limbs, inability to masticate or 
swallow at first, persistent loss of Power in Legs with 
Ancesthesia and Analgesia. No Babinski Sign. Intelligence 
and Silent L'hought unimpaired. Later, recovered Movement 
in Upper Limbs, and able to write. Complete Recovery after 
Eleven Months, except Sensation and Movement in Legs. 

Private W , admitted to 4th London General, May 15th, 

1915. This patient is speechless; he is lying in bed almost 
helpless. The eyes are wide open and have a pained, vacant 
stare, the brow is lined by many deep transverse furrowsi, and 
both the pyramidal es and the corrugatores supercilii are 
strongly contracted, so that at the root of the nose vertical 



96 WAR NEUROSES AND SHELL SHOCK 

furrows meet the transverse folds of the forehead, caused by 
the contracted occipito-frontahs muscle. The nostrils are 
somewhat dilated, and the mouth partially open, the naso- 
labial furrow and the other lines of the countenance are for 
the most part obliterated, so that the expression is like to that 
of intense terror. The face is flushed and perspiring. The 
hands are blue and cold, and the pulse at the A\Tist is hardly 
perceptible. The feet are cold. He is unable to sit up by 
himself; he cannot protrude the tongue beyond the teeth, 
although he made an effort to do so, and there were slight 
movements of his lip, as though he were attempting to articu- 
late. He comprehends all that is said to him, and tries to make 
himself understood. He cannot masticate because he cannot 
open his jaw; he has difficulty in swallowing, and at first 
there was considerable difficulty in giving him nutriment. 
Later, he was able to swallow jelly, lightly boiled egg and 
mince. He replies to questions, by alfirmative or negative nods 
of his head. He can read written and printed language, but 
when given a jiaper and pencil to write, so great was his 
difficulty in holding the pencil, and so pronounced was the 
tremor, that the pencil only marked a tangled skein on the 
paper, although it was evident that he was making an attempt 
to write. He cannot move his legs, which are rigid, and the 
right is decidedly more wasted than the left. There is jiatelar 
clonus and ankle clonus, but the plantar response was rather 
flexor than extensor. He has complete control over his 
sphincters. When I saw him a few days later he was better 
and playing draughts with another patient. He could not 
take the pieces up, but managed to push them on to the 
squares. This patient was able to converse with him by the 
deaf and dumb manual. He said he had learnt this sixteen 
days prior to admission. We also ascertained that his memory 
only goes back to the time he landed in England, but he had 
been told that two months previously a shell had burst near 
him and rendered him unconscious for three days ; a fragment 
of it had also caused a wound on the wrist, a sqar of which 
still existed. He had previously seen a sergeant and seven 
others killed by a shell. He had not had tetanus. He suffers 
with terrifying dreams. He is very intelligent. He can 
neither cough nor whistle nor blow out the cheeks. 

At first there was a frequent tendency to regurgitate fluid 
or to vomit it. His swallowing has improved, likewise his 
circulation, but now, ten days after admission, he has difficulty 
in swallowing; he cannot bend his legs, put out his tongue, 
or open his mouth, raise himself in bed, or turn without 
assistance. 



HYSTERICAL SPEECH DEFECT'S 97 

June 1st. — Steady improvement in his circulation, respira- 
tion, and power of swallowing soft food. . Still quite unable to 
move his legs. The transverse furrowing of his brow much 
less evident. He still dreams. 

June 7th. — Tested his sensibility with a needle; for the 
most part he does not respond at all to pricking; occasionally 
he indicated that he felt, once on the inner side of the right 
thigh, once on the inner side of calf of right leg. He was 
told to nod, and hold up his left or right hand, according to 
the side stimulated. He responded once on the left side of 
abdomen, but when he did respond there was marked delay. 
He did not feel the head of pin, at least no response was 
obtained; nor did he feel the vibrating tuning-fork on his 
limbs, although he responded with marked delay when put on 
his ribs or his forehead. But the vibration had to be of large 
amplitude. Tested with large tubes containing hot water and 
ice, he did not respond to the former, but he recognised the 
latter as cold, although there was considerable delay. A suc- 
cession of sharp pricks in the same place on the limbs produced 
no response to stimulus. He now smiles or even laughs, but 
there is no sound accompanying the expansion of his features. 
He still is unable to blow or whistle or phonate, although he 
understands everything; he cannot write. There is marked 
spasticity of the lower limbs. The patellar reflex can just be 
obtained; there is no clonus. Ankle clonus, not typical, is 
present. Plantar reflex : the only response is a slight flexor 
flicker of the little toes. The superficial abdominal reflex is 
just obtainable. 

Respiration is less shallow; abdominal movements are ob- 
servable, indicating descent and ascent of diaphragm of the 
normal quiet breathing of the male. 

He readily becomes fatigued; when he attempts to use his 
hands there is marked weakness and inco-ordination. None of 
the muscles, however, apjDcar wasted. Captain Clayton tried 
strong faradic stimulation to the larynx, but without any 
resulting phonation. 

August 2nd. — Patient sat up; for the first time was helped 
to stand on his feet by two persons, one on each side, support- 
ing him under the shoulder. When tested with tuning-fork, 
there was a marked delay — ten seconds on the hands before he 
gave an affirmative nod, whereas, placed on the forehead, he 
responded immediately. The pharyngeal reflex is absent. He 
can now blow out a candle at a distance of a foot. There is no 
real tone in the cough. Never any difficulty with his sphincters. 

October 18th. — He cannot feel below the knees. He can now 
write quite well ; sitting on the wheel chair, he plays billiards 

H 



98 WAR NEUROSRS AND SHELL SHOCK 

and even Badminton. He is very happy, but cannot speak, 
whisper, or whistle. He is able to stand, supported on both 
sides, but cannot raise his foot from the ground, though he 
has tried hard to do so. 

December 26th. — Said " Paddy " once, and with great exer- 
tion managed to stand, but he cannot raise a foot from the 
ground. There is anaesthesia and analgesia of the legs as high 
as the knee. The muscles are not wasted. 

March \2th. — He now speaks quite well. His speech returned 
in the following manner. He was sitting in his wheeled chair 
playing baseball, at which he was quite good, when a runner 
overturned him; the sudden emotional shock and surprise 
made him exclaim aloud, and since then he has quite recovered 
speech. But he cannot walk; there is still the stocking 
anaesthesia as high as the knee. He was consequently boarded 
out. 



" Severe Shell Shock " .• Blown into the Air in Trench ; does not 
remember falling; Aspect of Terror, Mutism and inability 
to phonate or to expire forcibly. Sudden Recovery of Speech 
Eight Months later. 

Private F H , age 20, admitted June 1st, 1915. 

Appearance. — Face flushed, eyes staring wide, pupils dilated, 
forehead wrinkled, mouth partially open, all the lines in the 
naso-labial fold obliterated. Hands and feet cold and blue. 

Pulse very small and feeble, hardly perceptible on left, just 
perceptible on right. 

He comprehends what is said to him, and tries to put out 
his tongue, but it hardly comes beyond the teeth. The lips 
move slightly in attempts to speak. He can read, and answers 
quite rationally and intelligently by writing. 

When asked how he was knocked out, he WTote : " There 
was something dropped into the trench. I think it was a 
shell; I felt myself go up into the air, but I cannot remember 
falling. The next thing I remember I was in a farm with 
some doctors. I don't know how long a time there was between. 
I have not had any dreams." 

He cannot whistle, he cannot cough, and cannot take a deep 
breath. The diaphragm, examined by X-rays, showed only 
slight movement of tranquil breathing, though he was told to 
cough. 

He remained in this condition for a few days ; his pulse and 
general condition improved. 

He was transferred after three months to Morden Hall. He 
was told that he had adenoids, and that an operation would 



HYSTERICAL SPEECH DEFECTS 99 

not only get rid of this trouble, but he could then speak. He 
had the operation performed under an anaesthetic, but on 
recovery he did not speak. The suggestion had no effect. 
He was often depressed at finding others regain their speech, 
and he, unable. He was a good fellow, and tried to get 
well. His joy was great when he recovered his speech, which 
returned quite suddenly. He was in a punt and it was turned 
over, and he was capsized into the water, which made him 
shout out. Practically he was mute for more than eight 
months. He often shouted words in his sleep about trench 
warfare, so he must have had dreams but forgot them. 



Why should these mutes, whose silent thoughts are 
perfect, be unable to speak? They comprehend all that 
is said to them unless they are deaf; but it is quite clear 
that in these cases their internal language is unaffected, 
for they are able to express their thoughts and judgments 
perfectly well by writing, even if they are deaf. The 
mutism is therefore not due to an intellectual defect, nor 
is it due to volitional inhibition of language in silent 
thought. Hearing, the primary incitation to vocalisation 
and speech, is usually unaffected, yet they are unable to 
speak ; they cannot even whisper, cough, whistle, or laugh 
aloud. Many who are unable to speak voluntarily yet 
call out in their dreams expressions they have used in 
trench warfare and battle. Sometimes this is followed by 
return of speech, but more often not. The sudden and 
varied manner in which these mutes recover their power 
of articulate speech and phonation is indicative of a 
refractory condition of the voluntary cortical mechanism 
of phonation. In some cases there is a history of a blow 
on the chest — e.g., from a sandbag — or of being buried 
and partially asphyxiated, and it is usual for the loss of 
speech to occur at the time of the shock. One patient, 
however, gave a history of difficult speech for two days 
after the shock; he lost his speech completely only after 
his vestibular reactions had been tested; while another, 
who after the same investigation became a deaf mute, 



100 WAR NEUROSES AND SHELL SHOCK 

recovered his speech upon hearing a man in the hospital 
say the Mord " Rose." He at once sat up and repeated 
the word, proving, as he said, " I could both speak and 
hear." Some of the earlier and more severe cases of 
shock followed by mutism were unable to expire forcibly 
enough to cough, to whistle, or to blow out a candle, but 
the less severe may be able to perform these acts and yet 
be unable to speak or whisper. The latter cases recover 
usually more quickly than the former, but sudden recovery 
may occur even in the severe cases. Thus a private who 
went to France October 1914, on August 9, 1915, was 
going to pick up a wounded comrade when a shell came 
and blew the wounded man to pieces, and he knew no 
more till about half an hour later, when he found himself 
deaf and dumb. There evidently were two factors in 
the production of the symptoms — the physical and the 
psychical — and of the two the latter was the greater. 
This patient was admitted under my care. Some weeks 
later his fellow soldiers thought he ought to hear and 
speak, and they adopted energetic measures to make him 
shout out for help. Two of them leathered him with 
a slipper and then nearly throttled him. He struggled 
and shouted, " Stop it." Another man dreamt he was 
falling over a cliff, shouted out, and recovered his speech. 
Another dreamt he was blown up by a trench mortar and 
shouted for help. Finding himself speaking, he continued 
to speak aloud, and did not go to sleep again for fear he 
might lose his speech. Another man, a deaf mute, was 
heard to speak in his sleep. He was told by a comrade. 
He said. " I don't believe it." Some have suddenly 
recovered their speech by crying out when unexpectedly 
feeling physical or mental pain; for example, one man 
cried out when some boiling tea was spilt over him, another 
when he was held down and his feet tickled. In most 
cases it is the sudden and unexpected which restores the 
function of the vocal mechanism. Thus a mute sergeant 



HYSTERICAL MUTISM AND APHONIA 101 

saw some soldiers larking in a punt and he suddenly 
shouted out, " You will be over." Occasionally the 
stimulus of a well-known chorus has broken down the 
refractory condition in the psychic mechanism of the 
voice, and the mute has surprised himself and others by 
finding himself singing. The recovery of speech may in 
some cases be only whispered speech — that is, aphonia 
supervenes. In other cases mutism is followed by stam- 
mering or stuttering. Such cases are often found on 
inquiry to have stammered, stuttered, or suffered with a 
hesitant speech at some time in their life prior to the 
shock. In many cases such a speech defect seems to have 
definitely originated as a result of the shock. I have 
recently seen a number of cases of hysterical aphonia and 
mutism occurring in soldiers who have been suffering 
with the effects of mustard gas. The aphonia and mutism 
can be cured by galvano-psychotherapy, but the voice 
frequently remains hoarse on account of the laryngitis, 
and by auto-suggestion relapses are frequent. This mutism 
of soldiers in no way differs from the pre-war description 
of hysterical mutism given by Bastian : " Some of the 
leading peculiarities of hysterical mutism are these. Its 
onset is very sudden, and often after a fright or some 
strong emotional disturbance. Sometimes it follows an 
hysterical seizure, either with or without paralysis of 
limbs. At other times it occurs without assignable cause, 
or it may be induced, as already stated, in some hypnotised 
persons by suggestion. The subjects of this disability are 
completely mute, presenting in this latter respect a notable 
contrast to ordinary aphasics, who so frequently make use 
of recurring utterances or articulate sounds of some kind. 
The intellect seems unimpaired, and they are able freely 
to express their thoughts by writing." Though the common 
movements of the lips, tongue, and palate are preserved, 
these parts (constituting the oral mechanism) are unable 
to act in the particular combinations needful for speech 



102 WAR NEUROSES AND SHELL SHOCK 

movements, in association with the other combinations of 
muscular action pertaining to the vocal mechanism. 

Bastian notes also that there may be more or less 
complete anaesthesia of the pharynx in hysterical mutism; 
this I have observed in some of the mutes. He notes 
that, as in these soldier mutes, hysterics may recover 
their speech suddenly as a result of a strong emotion, also 
as in the soldiers, recovery may be followed by stammering 
or stuttering. 

Bastian refers to a case in which frequently recurring 
attacks of mutism were generally associated with blind- 
ness or deafness, one or both. These conditions are also 
observed associated with mutism in soldiers, the subjects 
of shell shock. He also cites a case of his own : a sailor 
suffered with a great number of attacks of mutism (the 
first occurring as a result of fright) but previously he 
had not suffered from any nervous disease, but had led an 
active life in all parts of the world. We may therefore 
conclude that this mutism resulting after shell shock in 
no way differs from hysterical mutism. It appears, 
therefore, that there is nothing new in these functional 
disturbances and disabilities of speech and special senses, 
except it be their severity and frequency in men the 
subject of shell shock. 



Pathogenesis of Mutism 

We may now inquire into the pathogenesis of mutism. 
Charcot attempted to draw a distinction between aphonia 
and mutism. He adopted the doctrine of Marey and 
other physiologists that the larynx takes no part in whis- 
pered sounds. According to Charcot, therefore, aphonia 
(in which the power of whispering is preserved) is a result 
of a partial paralysis of the adductor muscles of the 
larynx ; while as to hysterical mutism Charcot writes : 
" If the individual suffering from the affection is unable 



PATHOGENESIS OF HYSTERICAL MUTISM 103 

to whisper, it is not because he is aphonic, or rather 
because his vocal cords do not vibrate; it is not because 
he has lost the common movements of tongue and lips— 
you have seen that this patient was able to blow and 
whistle; it is because he lacks the ability to execute the 
proper specialised movements necessary for the articula- 
tion of words. In other terms he is deprived of the motor 
representations necessary for the calling into play of articu- 
late speech." Charcot therefore believed the oral division 
of the speech mechanism only to be at fault in hysterical 
mutism. Wyllie maintains that, whilst this may be so in 
some cases, in a second group it is the laryngeal division 
of the speech mechanism which is at fault, and in a third 
set of cases both oral and laryngeal mechanisms are simul- 
taneously disabled. Charcot considered Hysterical mutism 
to be an instance of pure " motor aphasia " resulting from 
a functional trouble in Broca's region. Bastian, however, 
agrees with Wyllie that aphonia and mutism are most 
intimately related, differing in degrees only, " and the oral 
and vocal speech mechanisms are concerned in all speech 
mechanisms whether sonorous or whispered." Bastian 
considers that the clinical differences between simple 
aphasia and hysterical mutism force us to believe in the 
existence of a bilateral cortical disability in the third 
inferior frontal convolution. 

Sir Charles Bell, in his great work on the Expression of 
the Emotions, first drew attention to the influence which 
powerful emotions exercise upon the respiration. A part 
of the cortex controls the mechanism of breathing in the 
production of all voluntary audible sounds, and this, like 
the movements of the vocal cords, is represented in both 
halves of the brain, for the muscles of the two sides of 
the body which control the breath and phonation always 
act synergically and never work independently. In the 
oral division of speech mechanism the muscles of one side 
never act independently of the other. Bastian is probably, 



104 WAR NEUROSES AND SHELL SHOCK 

therefore, correct in asserting that it is a functional dis- 
ability of cortical structures in both hemispheres. Whether 
he is right in asserting that it may be localised in the third 
inferior frontal is another matter. I believe this mutism 
is due to the persistence of a fear-reaction inhibiting the 
voluntary cortical nervous centres which control phonation, 
for we have seen that mutes during sleep, owing no doubt 
to the excitation of dreams, may cry out and utter articu- 
late sounds. Many cases cannot produce any audible 
sound, for they are not only unable to talk or whisper, 
but to whistle, to utter a cry or to laugh aloud. I examined 
one case by means of X-rays and found the diaphragm 
could by no effort of the will be made to descend in a 
way sufficient so to fill the lungs as to produce an adequate 
expiratory blast * for coughing. He acquired this power 
later and was able to take a fairly deep inspiration, but 
he could not talk, whisper,- or whistle; even instinctive 
audible sounds such as a cough, a cry, or a sonorous laugh 
he was unable to produce ; the voluntary synergic mechan- 
ism of phonation was dissociated or inhibited ; the failure 
was in the cortex, for this mute, like many others, talked 
and uttered cries in his sleep. The return of tone in 
the voluntary cough is usually a herald of the return of 
speech. 

But why should the mute be able to express his thoughts 
in writing but not in verbal speech? Writing, like 
articulate speech, is acquired by imitation; they are part 
of the social heritage of mankind; the only human heri- 
tage connected with this acquired language is the employ- 
ment of the left hemisphere by the great majority of 
human beings as the active partner in controlling the 
lower motor centres of articulate and graphic expression 
of internal language, upon which thouglit, reason, and 
intelligence depend. But an individual who heard no 
articulate language would speak no articulate language; 
still, he could express all the primitive emotions and pas- 



PATHOGENESIS OF HYSTERICAL MUTISM 105 

sions by gesture, expression of eye and face, accompanied 
by modulated audible sounds. This primitive language 
is universal and understood by all mankind. It is the 
foundation upon which articulate language rests for ex- 
pressing the emotions and passions. Without modulation 
of the voice articulate language expresses no more feeling 
than graphic language. Now the images required for the 
production of the voluntary impulses necessary for articu- 
late speech by habit are initiated primarily in the auditory 
and glosso-kinsesthetic centres of the left hemisphere, but 
the mental images of audible sounds by which the voice 
is modulated to express the emotions are initiated in an 
inborn pre-organised mechanism in both hemispheres (see 
figure). 

In support of this may be mentioned the fact noted by 
Galton in his History of Twins, that whereas identical 
twins seldom showed similarity of character in hand- 
writing, the vocal intonation was usually similar. Again, 
it is true, as Lucretius observes in De Rerum Natures, 
that not only the features but the voice and hair of fore- 
fathers are repeated. 

Without the mechanism of phonation audible articulate 
speech, even whispering, is impossible. Two grades of 
speech defects may be observed in hysteria and as a 
result of emotional shock — viz. aphonia, in which phona- 
tion is extremely weak, and mutism, which is a complete 
loss of the power of phonation. Laryngoscopic examina- 
tion shows that the vocal cords are in a position of rest. 
Experiments on the higher apes show that stimulation of 
the laryngeal centre produces bilateral movements; there 
is then bilateral representation of the abductors and 
adductors of the vocal cords. Likewise there is bilateral 
representation of the muscles which control the breath in 
phonation {vide Fig. 34). 

Consequently we must suppose that mutism is caused 
by fear producing an emotional shock inhibiting the 



106 WAR NEUROSES AND SHELL SHOCK 

activities of the whole of the cortical structures connected 




Fig. 34. Diagram to Illustrate the Twofold Mechanism of Articulate Speech. 

A represents the lower articulator 'nervous mechanism ; Ph, the lower 
phonator nervous mechanism; LM, the left motor higher centre of 
articulation ; RM, the right motor higher centre of articulation ; 
LS, the left sensory higher centre of articulation ; RS, the right 
sensory higher centre of articulation ; the cortical centres of the 
speech zone in the two hemispheres are connected by fibres of the 
corpus callosum indicated by arrows ; PS, peripheral auditory nervous 
mechanism connected with the auditory centre of each hemisphere 
though mainly with the opposite. It will be observed that the thick 
interrupted line indicates the acquired path of voluntary control over 
the articulator mechanism in right-handed persons. If this is damaged 
in early life the right hemisphere becomes the active partner in 
the production of articulate speech. We are quite conscious of all the 
movements of the muscles of the tongue, the lips, the jaw, and the 
soft palate, by which the escape of the breath is modified so as to 
produce articulate sounds and language. We are conscious only of 
the pitch and in a measure of the loudness of the voice by the sense 
of hearing. The production of audible sounds varying in pitch and 
loudness expresses the emotions ; they are voluntarily initiated in 
both hemispheres and control equally both lower centres of phonation, 
laryngeal and respiratory. 

with phonation and production of audible sounds. Expe- 
rience has shown that the persistence of the fear-reaction 



FACTORS OF WAR NEUROSES 107 

of inhibition is largely due to the treatment which has 
been adopted in these cases of hysterical mutism. When 
soldiers first came over in the early days of the war suffer- 
ing with mutism and functional paralysis of a severe 
character such as the two cases recorded they evoked 
unbounded sympathy and attention. Such cases in males 
had never been seen before even by neurologists of wide 
experience, and the idea was pretty general that com- 
motional shock resulting in organic changes had taken 
place in the central nervous system. The French neuro- 
logists soon learnt that these functional cases are recover- 
able by electro-therapy and counter-suggestion at the hos- 
pitals and clearing stations at the front. For some time 
past we have also adopted this method of treatment of 
hysterical cases with marked success. 



The Predisposing Factors of War Psycho-neuroses 

Quite early in my experience at the neurological section 
of the 4th London General Hospital I found that the war 
neuroses and shell-shock cases had (in the majority of in-, 
stances) an acquired or inborn predisposition of emotivity. 

In my Lettsomian Lectures upon " The Effects of High 
Explosives upon the Central Nervous System," the 
following statement was made : — 

" A large majority of shell-shock cases occur in persons 
with a nervous temperament, or in persons who were the 
victims of an acquired, or inherited neuropathy; also a 
neuro-potentially sound soldier in this trench warfare 
may, from stress of prolonged active service, acquire a 
neurasthenic condition. If in a soldier there is an inborn 
timidity, or neuropathic or psychopathic taint, causing a 
locus minoris resistentice, it necessarily follows that he will 
be less able to withstand the terrifying effects of shell fire 
and the stress of trench warfare." 

I based this conclusion on the following facts of cases 



108 WAR NEUROSES AND SHELL SHOCK 

admitted to the Maudsley Hospital Extension during six 
months : — 

I. History reported on in 156 cases (shock). 
II. No history ,, ,, 80 ,, ,, 

III. No history of shock in 40 ,, 



I. — A. History predisposing to shock in 111 cases; 
B. No history predisposing to shock in 45 cases. 

Cases. 
A. (a) Nervous predisposition (previous nervous break- 
down, timid disposition, neuropathic tempera- 
ment as revealed by family history, etc.) . 52 

(b) Epilepsy (pre-war 20, since war 5). Of the 

latter one had head injury and two bits of 
bone removed in 1904, and one developed fits 
after shrapnel wound of head (frontal) tre- 
phined during war . . . . .25 

(c) Shock or accident (pre-war) . . . .11 
Traumatic (pre-war) ..... 9 

(d) History of insanity (patient 2, family 7) . , 9 

(e) Mental defectives ...... 5 

Pierre Marie, Nonne, and others have come to similar 
conclusions. 

Gaupp gave expression to a similar view : " In the 
psycho-physiological make-up of the soldier is to be found 
a most important cause of neuroses. The psychiatric 
analysis of the individual cases points to a psychopathic 
basis in most of the war psycho-neuroses and psychoses, 
often when the history, as recorded, reveals nothing." 
Birnbaum in his initial review of the literature on war 
neuroses and psychoses came to the following conclusion : 
" Soldiers developing nervous and mental disorders show 
in the great majority of cases a predisposition (by which is 
understood not only a congenital, but also an acquired 
disposition) such as may be observed following the chronic 
abuse of alcohol, and earlier head injuries with concussion." 



HISTORY OF ONE HUNDRED CASES 109 



Comparative Study of the Personal History of 100 
Gases of War Psychosis and 100 Gases of 
Wounded 

At my suggestion and under my direction Captain J. M. 
Wolfsohn of the American Army Medical Service inves- 
tigated the personal history and the leading nervous state 
in 100 of my cases of soldiers suffering with shell shock 
or war psycho-neuroses (neurasthenia and hysteria), and 
compared the same with 100 surgical cases suffering with 
wounds under the care of Captain Turner at the 4th London 
General Hospital. 

The three following tables of the results are quoted from 
his paper in The Lancet, February 3rd, 1918. 

Table I. — Family ^History. 

Percentages of characteristics named in (A) Neurosis, 
(B) Wounded. 

(A) (B) i (A) (B) 



Nervousness . . . 64 15 

Alcoholism (parents \ _^ „ . 

and grandparents) j 

Teetotaller (parents ) ^rw i p 

and grandparents) j 

Irritability of temper 36 12 

Insanity .... 34 

Epilepsy .... 30 



12 



6 



Tuberculosis — im- 
mediate family 

Tuberculosis — rela- 
tives 

Stigmata . . . . 10 

Positive history for \ 
one of several of \ 74 
above J 



4 


38 



Table II. — Personal History. 

Percentages of characteristics named in (A) Neurosis, 
(B) Wounded. 

(A) (B) 



Stigmata .... 34 

Previous nervousness 66 

Fears 50 

Head injury ... 38 

Epilepsy .... 8 

Tobacco — excessive , 8 

Alcohol — excessive . 6 

,, — teetotaller 48 

Married .... 42 

Moody . ... 55 

Previous breakdown 2 



4 
12 

8 

12 



4 

16 

20 

28 

8 





Enuresis .... 
Frights in childhood 
Excessive religion 
Positive personal his- ) 

tory / 

Positive family and ) „^ 

personal history / 
Recurrences and re- ) _ . 

lapses j 

Acquired neurosis . 12 



(A) (B) 


12 


4 


4 





6 






76 12 



110 WAR NEUROSES AND SHELL SHOCK 

Table III. — Present Illness. 
Percentages of conditions named in (A) Neurosis, (B) Wounded. 



(A) 


(B) 




(A) 


(B) 


Service . 12 mos. 


10 mos. 


Insomnia . 


. 86 





Unconscious \ „^ 
ness j ^ 


24 


Fears . 
Dreams 


. 76 

. 88 



50 


Dazed . . 84 


24 


Fatigue . 


. 94 


40 


Tremor . . 84 


12 


Headache 


. 88 


36 


Poor memory 88 


4 


Moody 


. 92 





Poor concen- ) ^^ 


d. 


Vertigo 


. 74 


8 


tration j 


rr 


Fits . . 


. 10 






Conclusions 

From this study of 100 cases of war psycho-neuroses and 
100 cases of somatic injuries produced in the firing-hne one 
can draw the following 'conclusions : — 

Cases of war neurosis are very rarely associated with 
external or somatic wounds. The vast majority of the 
psycho-neurotic cases studied were among soldiers who 
had a neuropathic or psychopathic soil. In 74 per cent, 
of these cases a family history of neurotic or psychotic 
stigmata, including insanity, epilepsy, alcoholism, and 
nervousness, was obtained, whilst a previous neuropathic 
constitution in the patient himself was present in 72 per 
cent. Col. Gordon Holmes has written to me to say that 
a considerable number of the wounded that he has seen 
suffer with psycho-neuroses. Probably the cases he sees 
are especially cranial and spinal injuries. Of course we 
know that these injuries will cause traumatic neuroses. 
M. Maurice Didc, Chef du Centre Neuro-psychiatrique de 
la VHP Armee, says : " Neuropathic disorders are excep- 
tional in the real wounded ; moreover, cases of mental 
confusion are almost without example in cases of head 
injury." He does not like the term "mental confusion," 
but prefers " battle hypnosis," which can be cured in a 
few days. 

A gradual psychic shock from long-continued fear, 



NEUROPATHIC TENDENCY 111 

together with the sudden change from quiet, peaceful 
environment to the extraordinary stress and strain of 
trench fighting, is the chief predisposing cause of war 
psycho-neurosis in soldiers with neuropathic predisposition. 
In fact, these factors may be the cause of the neurosis jper se. 

The history of the individual previous to enlistment 
has an influence on the character and gravity of the 
symptoms of the neurosis. 

It is perfectly certain that among the general population 
there is a large number of men who are constitutional 
neuropaths or psychopaths, and in a country where con- 
scription exists the majority of these are recruited. The 
stress of war, and especially the stress of this war is suffi- 
cient to convert a latent tendency to psycho-neuroses or 
psychoses into a pronounced functional disability. The 
calling up for military service, the training and the rigorous 
discipline are sufficient, without active service at the front, 
to reveal neurotic or psychotic predisposition. This fact 
was known in Germany before the war, as the following 
quotation shows — 

" The manifestations seen in times of war do not differ 
from those seen in the times of peace." " For the last 
fifteen years," says Stier, " I have been observing cases 
of hysteria in the army, and before the outbreak of war 1 
had been able to collect more than 1000 cases. A com- 
parison of my pre-war and recent experience shows that 
manifestations occurred in practically the same proportions 
in peace time as have appeared since war broke out. 
Indeed, we may state that the war has not created anything 
new in the way of manifestations ; it has merely revealed the 
fact that amongst a certain percentage of patients, on account 
of constitutional factors, an exceptionally strong tendency to 
react in a pathological manner to affective experiences exists^ 

The above-mentioned facts show the importance of 
studying what a man is born with and what happened 
after birth when recruiting and subsequently assigning him 



112 WAR NEUROSES AND SHELL SHOCK 

to a category for military service. It is not of much use 
sending a constitutional neuropath or psychopath to the 
front; he will in all probability break down. 

Psycho-neuroses in Recruits and Conscripts 

An interesting and instructive report to the Medical 
Research Committee by Lieut. -Col. F. W. Burton-Fanning 
upon Neurasthenia in Soldiers of the Home Forces 
clearly demonstrates the fact that large numbers of men 
in civil life in all grades of society carrying on their occu- 
pations are, when conscripted, the subjects of neurasthenia. 
Consequently this nervous affection is of great importance 
from a military point of view as a cause of loss of man- 
power to the Army. . As the author remarks, numbers of 
these patients have spent far more time in hospitals and 
convalescent homes than with the units; it is therefore 
open to doubt whether it is worth while training such 
men for soldiers, as it would be more profitable to spend 
the monc}'^ and energy in the manufacture of munitions. 

Another fact which is brought home to all those who 
have had the care of cases of war psycho-neuroses is, that 
the signs and symptoms of hysteria and neurasthenia of 
men who have been to the front and have been invalided 
home (except those in which there has been definite evi- 
dence of cerebral or spinal commotion, burial or gassing) 
in no way differ essentially from the signs and symptoms 
of hysteria and neurasthenia of men who have never been 
out of England. I have seen both hysteria and neuras- 
thenia arise from the fear of conscription, or, having been 
conscripted, an hysterical crisis has occurred when it 
became known that the conscript would be in a draft for 
general service abroad. 

Burton-Fanning found that the majority of cases of 
hysteria and neurasthenia owe their condition to an inborn 
temperamental neurotic disposition, which accords en- 
tirely with my own experience of recruits and of soldiers 



WAR NEUROSES IN RECRUITS 113 

suffering from these nervous affections. Indeed, the 
inborn factor dominates, as a rule, in proportion to the 
failure to discover adequate cause of stress arising from 
military service. These conscripts, as Burton-Fanning 
says, disagree with the doctor's " Fit for Service." " They 
resent being found fit and bring certificates of their un- 
fitness for which they are willing to pay considerable 
sums." Such cases give a typical proof of Dejerine's 
dictum of the essential condition of neurasthenia being a 
continued emotivity and mental preoccupation which in 
the recruit's case concerns their unfitness or unwillingness 
for military service. 

In such a mental attitude, therefore, they start their 
military career under a cloud and find their comrades not 
over congenial. Many of the men, especially clerks, are 
quite unfit for hard training and suffer with mental and 
bodily fatigue, aggravated by insomnia and anxious mental 
preoccupation. They complain of the usual symptoms of 
neurasthenia — viz. tremors, fatigability by mental or 
bodily effort; loss of confidence and irresolution; hyper- 
aesthesia, paraesthesia, and pains which they consider to 
be rheumatic ; fainting attacks ; praecordial pain and pal- 
pitation ; feelings of dizziness ; insomnia and dreams ; loss 
of appetite and anorexia ; headache and gastric troubles. 
The relation of the genital functions to emotivity is well 
known, and in civil life sexual disorders, sexual abuse, and 
fears regarding impotence play an important role in the 
genesis of neurasthenia. I have not found a large percen- 
tage of officers and men sent home from the front suffering 
with neurasthenia who have been mentally preoccupied 
or who have complained of fear connected with the genital 
functions. In fact, they are few as compared with those 
seen in civil life. Each individual reacts to emotions 
according to his personality, and each physical reaction, 
whether kinetic, cardiac, respiratory, gastric, or genital, 
when exhibited for the first time, is subconscious. 
I 



114 WAR NEUROSES AND SHELL SHOCK 

The Psychology of " Soldiers' Dreams " in Relation 
to Neurasthenia 

Terrifying dreams occur in a large proportion of neuras- 
thenic soldiers from the front, and, inasmuch as their 
existence is a sign of the continuance of the emotivity, 
therefore of their unfitness to return to General Service, 
it will be well to consider at some length the subject of 
" Soldiers' Dreams " and what they signify, for it will 
enable us to understand the fundamental principles under- 
lying the causation of war psycho-neuroses, especially 
neurasthenia, or, as some authorities prefer to term the 
condition, " anxiety-neurosis." I am in entire agreement 
with McCurdy, who states : " The best criterion I have 
been able to discover for permanence of symptoms is the 
presence of repeated nightmares of actual fighting, I was 
not able to find a single patient who had once shown these 
symptoms and subsequently improved without regular 
and protracted treatment. These remarks refer more par- 
ticularly to the anxiety states rather than the conversion 
hysterias." 

In books on psychology and psycho-analysis I find little 
or no reference to the psychology of soldiers' dreams. 
Yet, in that greatest of all works on human thought and 
action, we find reference to the dreams of soldiers and 
their significance, so true to the present-day experiences, 
that I shall refer to them and the possible classical .source 
of their inspiration. 

In the De Rerum Natures of Lucretius he says — 

" And generally, to whatever pursuit a man is closely 
tied down and strongly attached, on whatever subject 
we have previously nuich dwelt, the mind having been 
put to a more than usual strain in it ; during sleep we for 
the most part fancy that we are engaged in the same ; 
lawyers think tliat they plead causes and even draw up 
covenants of sale, generals that they fight and engage in 



PSYCHOLOGY OF SOLDIERS' DREAMS 115 

battle, sailors that they wage and carry on war with the 
winds. We think that we pursue our task and consign 
it when discovered to writings in our own native tongue. 
So all other arts and pursuits are seen for the most part 
during sleep to occupy and mock the minds of men." 

Lucretius next calls attention to the evidence of dreams 
in animals — 

" And often during soft repose the dogs of hunters do 
yet all at once throw about their legs and suddenly utter 
cries and repeatedly sniff the air with their nostrils as 
though they had found and were on the tracks of wild 
beasts." 

In another passage Lucretius says — 

" Again the minds of men which pursue great aims under 
great emotions often during sleep pursue and carry on the 
same in like manner; kings take by storm, are taken, 
join battle, raise a loud cry as if stabbed on the spot." 

In Shakespeare there are two passages which may have 
had their source of inspiration in the De Rerum Naturce 
of Lucretius — viz. the speech regarding Queen Mab by 
Mercutio and that of Lady Percy to Hotspur. 

As Lucretius says, a man dreams of whatever pursuit 
he is closely tied down to; at the present day the soldier 
dreams that he is in the trenches fighting Germans, or he 
hears and sees the shells bursting, shouts in his sleep, and 
wakes with a start. How truly Shakespeare describes this 
when he says — 

" Sometimes she [Queen Mab] driveth o'er a soldier's neck, 
And then dreams he of cutting foreign throats, 
Of breaches, ambus cadoes, Spanish blades, 
Of healths five fathom deep ; and then anon 
Drums in his ear ; at which he starts and wakes. 
And, being thus frighted, swears a prayer or two 
And sleeps again. . . ." 

(In the quarto 1597 the text had " countermines " 



116 WAR NEUROSES AND SHELL SHOCK 

instead of " Spanish blades," which seems singularly 
appropriate just now.) 

In Lady Percy's speech to Hotspur there is the following 
passage — 

" Why hast thou lost the fresh blood in thy cheeks ; 
And given my treasures and my rights of thee 
To thick-eyed musing and cursed melancholy ? ^ « 

In thy faint slumbers I by thee have watch'd 
And heard thee murmur tales of iron wars : 
Speak terms of manage to thy bounding steed, 
Cry, ' Courage ! to the field ! ' And then hast talk'd 
Of sallies and retires ; of trenches, tents ; 
Of palisades, frontiers, parapets ; 
Of basilisks, of cannon, culverin ; 
Of prisoners' ransom and of soldiers slain, 
And all the currents of a heady fight. 
Thy spirit within thee hath been so at war, 
And thus hath so bestirr'd thee in thy sleep, 

• That beads of sweat have stood upon thy brow, 
Like bubbles in a late-disturbed stream ; 
And in thy face strange motions have appear'd. 
Such as we see when men restrain their breath 
On some great sudden hest. O ! what portents are these ? " 
(First Part of Henry IV, Act II, sc. iii.) 

The experiences of the war have shown us how true the 
psychology of Lucretius and Shakespeare is as regards 
soldiers' dreams and how utterly wrong the following 
statement of Brill, a follower of Freud, is — 

" Dreams accompanied by fear are of a sexual nature ; 
the ideation causing the fear in the dream was once a 
wish which was later subjected to repression." 

The two fundamental motives to human action are 
undoubtedly the preservation of the individual and the 
preservation of the species — that is, self- conservation and 
propagation. 

^ McCurdy, in discussing the Anxiety Neuroses of Soldiers, says : 
" The man who is visited by his wife or his sweetheart is a disappoint- 
ment both to himself and his visitor in that it is impossible for him to 
give any proof of his affection. This finds expression in a manifestly 
obvious way through the symptoms of impotence, which is, as far as 1 
have been able to learn, universally present in the anxiety state, either 
as such, or in the form of its equivalent lack of erotic feeling." — " War 
Neuroses," Psychiatric Btdletin of New York, July 1917. 



SOLDIERS' DREAMS AND FREUD 117 



Soldiers' Dreams and the Doctrine of Fread 

Freud, in developing his psychology of the psycho- 
neuroses, found that the dream plays a very important 
part in the psyche of the individual. The dream, accord- 
ing to Freud, is not a senseless jumble, but a perfect 
mechanism, and, when analysed, it is found to contain the 
fulfilment of a wish ; it always treats of the inmost thoughts 
of the personality, and for that reason gives us the best 
access to the unconscious. " No psychanalysis is com- 
plete, nay possible, without the analysis of dreams. The 
dream not only helps us to interpret symptoms, but is 
often an invaluable instrument in diagnosis and treatment. 
The causative factors of many neuroses are extremely 
vague and usually unconscious to the patients, and it is 
by means of the dreams that the underlying factors are 
disclosed." 

The doctrine of Freud, and still more that taught by 
his followers, does not take into consideration, as a psycho- 
genic factor of neuroses, the conflict caused by suppression 
of painful memories of experiences associated with the 
emotion of fear in relation to self-conservation. 

Capt. W. H. R. Rivers, in a recent interesting article, 
makes the following statement — 

" Not a day of clinical experience passes in which Freud's 
theory may not be of practical use in diagnosis and treat- 
ment. The terrifying dreams, the sudden gusts of depres- 
sion or restlessness, the cases of altered personality which 
are among the most characteristic of the present war, 
receive by far the most natural explanation as the result 
of war experience which, by some pathological process, 
often assisted later by conscious activity on the part of 
the patient, has been either dissociated or is in process of 
undergoing changes which will lead sooner or later to this 
result. While the results of warfare provide little ex- 
perience in the favour of production of the functional 



118 WAR NEUROSES AND SHELL SHOCK 

nervous disorders by the activity of repressed sexual 
complexes, I believe they will afford abundant evidence 
in favour of the validity of Freud's theory of forgetting." 

It will be observed that Rivers accepts the validity of 
Freud's theory of the Unconscious, but asserts that his 
experience does not support the pre-war notion of Freud 
and his adherents that the psycho-neuroses were due in 
all cases to repressed sexual complexes. 

The special inerit of Freud's theory is that it provides a 
psychological theory of dissociation of the factors upon which 
it depends and of the processes by which its effects can be 
overcome. According to the views long current in psy- 
chology, experience is remembered in so far as it is frequently 
repeated and according as it is interesting and arouses 
emotion pleasant or unpleasant, and forgetting is a process 
which stands in no special need of explanation. The dreams 
of soldiers, some of which I will relate to you, exhibit in a 
striking manner how an incident of war associated with 
emotional shock is graven on the mind, for it continually 
recurs in a vivid and terrifying manner in their dreams, 
half-waking state, and in some few cases even in the 
waking state, constituting hallucinations. Forgetting this 
painful experience is a natural defensive reaction. 

Dreams in Relation to the Unconscious 

According to Rivers, Freud's theory affords an explana- 
tion of the mechanism of forgetting, and especially the 
forgetting of an unpleasant experience by a thrusting of 
it out of consciousness and keeping it out. This mechan- 
ism Freud terms the Censor, which is supposed to act as 
a constant guard, only permitting the arousing of the 
repressed experiences to reach consciousness in sleep, in 
the half-waking state, in hypnosis and automatic states 
in which the normal control of the censor is removed or 
weakened. Even in such states it is only permitted to 



DREAMS IN RELATION TO NEURASTHENIA 119 

become manifest in an indirect or symbolic manner. But 
does this hypothetical censor differ essentially from in- 
hibition exercised by the highest centres of control, centres 
upon which voluntary attention depends ? For voluntary 
attention would be made ineffectual by emotional per- 
turbation. Consequently the inhibitory functions of the 
higher centres of control must be continually and, after a 
variable time following the emotional shock, unconsciously 
exercised in repressing the recollection of the experience. 
At first during the conscious waking state the experience 
which caused the emotional shock crosses the threshold 
of consciousness in spite of the voluntary attempts of the 
patient to divert the mind, causing mental perturbation 
accompanied by visible emotional disturbances. The in- 
dividual is conscious at first of this conflict, but its very 
continuance tends in the normal individual to make it 
pass into the unconscious. But this does not mean that 
the struggle is not going on ; for every now and then the 
painful terrifying experience may in some cases rise into 
consciousness and cause marked emotional disturbance and 
depression. I have met with many striking instances of 
this in officers and men who have returned from the front 
suffering from neurasthenia. 



Dreams in Relation to Neurasthenia of Soldiers 

As I have frequently observed, the persistence of terri- 
fying dreams, often of one particular horrible experience 
recurring with great frequency, and even in the half- 
waking state persisting in the mind, proves that the struggle 
is going on. Indeed, experience shows that while these 
dreams persist the other signs of neurasthenia exist. In- 
deed, a prognosis of recovery largely depends upon whether 
the patient has refreshing sleep, undisturbed by these 
terrifying dreams. We may assume that these dreams 
cause a state of continuous emotivity. 



120 WAR NEUROSES AND SHELL SHOCK 

Indeed, Dejerine points out that the dream can even, 
in some cases, cause an emotivity if it introduces into 
consciousness images sufficiently vivid to be considered as 
an emotive excitation, and when persistent and terrifying 
as it is in the case of soldiers suffering with war psycho- 
neuroses, an acquired emotivity may be engendered in a 
neuro-potentially sound individual. 

Emotional and Gommotional Shock in Relation to 
Soldiers' Dreams 

In a general way emotion is a reaction of the personality. 
Under intense emotional shock an individual may be 
deprived of even elemental perceptions; not seeing any 
more, not hearing any more, not feeling any more, trans- 
formed into a simple automaton, the subject, as Dejerine 
says, is, so to speak, in a state of psychological syncope. 
Soldiers under shell fire may become for the time being 
mere automata, and wander away unconscious of what 
they have been doing ; it is difficult to decide whether they 
are suffering from emotional shock or from commotional 
shock without visible injury caused by forces generated 
by high explosives. 

The emotional shock may be the result of terror or 
horror, and one must differentiate between these two forms 
of contemplative fear, in both of which the imagination 
plays an all-important part. 

Sir Charles Bell says — 

" Horror differs both from fear and terror, although 
more nearly allied to the last than the first. It is superior 
to both in this, that it is less imbued with personal alarm. 
It is more full of sympathy with the sufferings of others 
than engaged with our own. We are struck with horror 
even at the spectacle of artificial distress, but it is peculiarly 
excited by the real danger or pain of another. Horror is 
full of energy; the body is in the utmost tension, not 
unnerved by fear." 



WAR NEUROSES AND SUPPRESSED FEAR 121 

Terror is more self-regarding; horror is more altruistic. 
Both sentiments are based upon the primitive emotion of 
fear. 

The character of the dreams of soldiers shows that they 
are imbued with terror or horror, sometimes with both. 



Secreto-Motor and Vaso-Motor Reactions the Out- 
come of Suppressed Fear during the Waking 
State 

The subconscious memories of war experiences con- 
nected with fear and the self-conservative instinct are 
probably continually acting upon the lower cerebro-spinal 
autonomic centres, accounting for many of the secretory 
and motor phenomena observed in war psycho -neuroses. 
The motor disorders and disabilities met with in soldiers 
suffering from emotional or commotional shock are fre- 
quently of the nature of instinctive defence reactions. 
Thus, a tic of the head has acquired the name of the 
" dodging reflex," being the spontaneous movement which 
would take place upon hearing a shell coming; this tic 
is especially liable to be excited by any sudden noise or 
sound. Again, many of the motor paralyses and dis- 
abilities we know to be associated with fear by popular 
metaphor. Thus, " dumb with fear," " quaking or tremb- 
ling with fear," " paralysed by fear," and the crouching 
attitude of many " shell shock " cases suggests the 
defensive reaction of concealment by immobility — in 
contradistinction to that by flight or fight. In these latter 
conditions an increased discharge of muscular energy is 
required, a rise of blood pressure, and an increased quantity 
of glycogen is converted into sugar. This is effected 
through the splanchnic nerves exciting an increased 
mobilisation of adrenalin from the suprarenal glands. 

A very common vaso-motor phenomenon exhibited by 
soldiers suffering with shock, especially those who are 



122 WAR NEUROSES AND SHELL SHOCK 

troubled with terrifying dreams, is aero-cyanosis, cold- 
blueness of the extremities, hence the popular expression 
of " blue funk." In about 10 per cent, of severe cases of 
shock there are signs of Graves's disease — viz. some 
degree of exophthalmos, von Graefe's sign, Moebius's sign, 
tachycardia, fine rhythmical tremors 8 or 9 per second, 
and the thyroid gland is more easily palpable than normal. 

Secreto-Motor and Vaso-Motor Reactions the Out- 
come of Terrifying Dreams 

Many of my cases were unable to recollect their dreams, 
but complained of waking up in a fright and in a cold 
sweat. Kant ^ explains this by saying that — 

" In the waking state we do not remember any of the 
ideas which we might have had in sound sleep. From 
this last follows, however, only this much, that the ideas 
were not clearly represented while we were waking up, but 
not that they were obscure also while we slept." 

Further, he says — 

" I rather suppose that ideas in sleep may be clearer 
and broader than even the clearest in the waking state. 
For man at such times is not sensible of his body. When 
he wakes up his body is not associated with the ideas of 
his sleep, so that it cannot be a means of recalling this 
former state of thought to consciousness in such a way as 
to make it appear to belong to one and the same person. 
A confirmation of my idea of sound sleep is found in the 
activity of some who walk in their sleep, and who in such 
a state betray more intelligence than usual, although in 
waking up they do not remember anything." 

In the dreams of soldiers, when the perceptual relations 
of the body to the external world are dissociated and the 
inhibitory functions of the highest cortical centres of 
voluntary attention are in abeyance, ideas of past war 

1 Drrams of a Spirit Seer. 



DREAMS AND INSTINCTIVE REACTIONS 123 

experiences are revived with great vividness in the great 
majority of cases, even in those who are unable to recollect 
their dreams. For besides those cases which wake up in a 
fright and cold sweat, there have been numerous instances 
of soldiers who have walked in their sleep and many others 
who have talked, shouted out orders and cried out in 
alarm as if again engaged in battle; some of these have 
been mutes. But the strangest phenomena of forgotten 
dreams of soldiers suffering with shock are observed in 
those who in their sleep act as though they were back 
in the trenches engaged in battle, and go through all the 
pantomime of fighting with bomb, with bayonet, with 
machine-gun and with rifle, and yet remember nothing of 
these happenings when they awaken. One or two cases 
of this kind had to sleep in the padded room in order 
to prevent them doing injury to themselves. Evidently 
during their sleep vivid imaginings of their previous ex- 
periences are arousing defensive and offensive reactions 
in face of the imaginary enemy. 

As these dreams cease to disturb sleep, so these manifes- 
tations of fear tend to pass off and give place to the sweet 
unconscious quiet of the mind. Occasional!}^ during the 
waking state contemplation of the horrors seen provokes 
hallucinations or illusions which may lead to motor 
delirium or insane conduct. At least this is the inter- 
pretation I should put upon the symptomatology of the 
two following illustrative cases : — 



1. An officer was admitted under my care in a state of 
restless motor delirium; he moved continually in the bed, sat 
up, passing his hand across the forehead as if he were witnessing 
some horrifying sight, and muttering to himself; yet, when 
interrogated, he answered quite rationally. This motor de- 
lirium I associated with the continuous effects on the conscious 
and subconscious mind of the terrible experiences he had gone 
through. His whole company had been destroyed, and, while 
talking to a brother officer, the latter had half his head blown, 
off by a piece of a shell. The patient improved very much, but 



124 WAR NEUROSES AND SHELL SHOCK 

a relapse occurred after a night disturbed by terrifying dreams. 
Even after a year had elapsed his nervous system showed a 
marked emotivity and he had to be boarded out of the service. 
2. Paroxysmal Attacks of Maniacal Excitement following Shell 
Shock. — ^A private, aged 19, was admitted suffering with shock 
due to emotional stress and shell fire. He suffered with 
terrifying dreams, and after he had been in hospital a short 
time he developed sudden paroxysmal attacks of maniacal 
excitement. The first attack occurred suddenly. One after- 
noon he had been helping as usual in the kitchen, and then he 
went and lay down on his bed and apparently went to sleep; 
he suddenly woke with a startled, terrified look, became flushed 
in the face, sweated profusely, and made for the door as if to 
get away from some terrifying conditions. He was with diffi- 
culty restrained. He remained in this excited state, glaring 
rapidly from side to side, giving one the impression that he was 
suffering from terrifying hallucinations of sight and hearing, 
although he would make no response to interrogation. He did 
not recognise his wife, the doctor, or the sisters. Once when 
I, accompanied by two medical officers in uniform (strangers), 
came up to speak to him he became violently agitated as if 
some terrifying conditions had been aroused by the sight of 
the uniforms ; the face was flushed and he sweated so profusely 
that the perspiration dripped in a stream off his nose. The 
attacks would last from a few hours to a few days ; they came 
on quite suddenly like an epileptic fit and often without any 
apparent cause. They became more severe and frequent, and 
when we had moved the neurasthenic patients to the Grove- 
lane schools he one day ran out of the building into the play- 
ground and attempted to get over the wall. He was brought 
back, and I saw him sitting in the ward on his bed; his head 
was buried in his hands ; I spoke to him ; he immediately 
got up, looked at me in the most terrified manner, and made for 
the door; it required four orderlies to restrain him, and he 
fought and kicked violently, exhibiting great strength and 
nervous energy. Much to my regret I found it necessary to 
have him sent to Napsbury. I have heard that he has made a 
complete recovery and has been discharged. It may be men- 
tioned that there was no history obtainable of epilepsy or 
insanity in the family. 

This case rather suggests the psychic equivalents of 
epilepsy in the attacks. 

I have asked numbers of soldiers and officers to write 
down their recurrent dreams for me, and I possess a 



DAY DREAMS AND DEFENSIVE REACTIONS 125 

considerable number of such records. Almost without 
exception they have a direct relation to war experiences. 
This method avoids suggestion on my part by putting 
leading questions. I ask them to state how far the dream 
is related to previous experience and whether any par- 
ticular dream or dreams constantly recur. I tell them that 
a correct description in writing will prove a valuable means 
of throwing off the terrifying effects. In only one instance 
was there any pronounced sexual basis ; the subject of 
that particular dream, which constantly recurred, was 
of a disgusting and horrible nature, and when it occurred 
gave rise to most distressing hysterical manifestations. 
The patient was a private and wrote down the nature 
of this dream on condition that I would never make it 
public. Whether, as he affirmed, he had actually wit- 
nessed the scene, or whether, as is possible, it was gross 
exaggeration, or a delusion arising from a recurrent dream, 
I am unable to say. 

The dreams are nearly always visual and auditory re- 
presentations, shells exploding which they see and hear, 
machine-guns firing, etc., and are associated with the 
emotion of fear ; for the patients wake up in a fright and 
cold sweat. 

In one case, however, the patient when just dozing off 
was disgusted by the smell of dead bodies, and this smell 
was followed by horrifying visions of putrified corpses. 
He explained it by the fact that he had been serving some 
time at the front, and the continuous shell fire had shat- 
tered his nerves, rendering him unable to continue to fight 
in the trenches, and he had latterly been employed in 
burying the dead. 

A very common complaint of soldiers is a falling feeling ; 
this is not limited to men in the R.A.F., although it is 
usual for them to dream of their especial experiences. 
A not infrequent dream is that they are engaged in bomb- 
ing or fighting; that their machine is hit, and that they 



126 WAR NEUROSES AND SHELL SHOCK 

are descending in an aeroplane in flames. It does not 
necessarily mean that this has been their experience, but 
the anticipation of the possibility of such a catastrophe 
from the knowledge of the fate of others has left such a 
deep impression on the mind that the imagination provides 
the source of the terrifying dream. 

A very remarkable dream of an officer of sound nervous 
constitution is worthy of full consideration, and I will 
merely record what he wrote, for it clearly shows his dream 
accords with his experience, and it illustrates how true is 
the observation of Lucretius — 

" And generally to whatever pursuit a man is closely 
tied down and strongly attached, on whatever subject we 
have previously much dwelt, the mind having been put 
to a more than usual strain in it, we for the most part 
fancy we are engaged in the same." 

This is one instance in which the individual has dreamt 
the experience of hunger and thirst in addition to battle 
experience. 

Recorded Dream of a Second Lieutenant. 

" During the five days spent in the village of Roeux I was 
continually under our own shell fire and also continually liable 
to be discovered by the enemy, who was also occupying the 
village. Each night I attempted to get through his lines 
without being observed, but failed. On the fourth day my 
sergeant was killed at my side by a shell. On the fifth day I 
was rescued by our troops while I was unconscious. During 
this time I had had nothing to drink or eat, with the exception 
of about a pint of water. 

" At the present time I am subject to dreams in which I hear 
these shells bursting and whistling through the air. I also 
continually see my sergeant, both alive and dead, and also my 
attempts to return are vividly pictured. I sometimes have in 
my dreams that feeling of intense hunger and thirst which I 
had in the village. When I awaken I feel as though all strength 
had left me and am in a cold sweat. 

" For a time after awaking I fail to realise where I am, and 
the surroundings take on tlie form of the ruins in which I 
remained hidden for so long. 



EFFECTS OF DREAMS NEXT DAY 127 

" Sometimes I do not think that I thoroughly awaken, as I 
seem to doze off, and there are the conflicting ideas that I am 
in the hospital, and again that I am in P>ance. 

" During the day, if I sit doing nothing in particular and I 
find myself dozing, my mind seems to immediately begin to 
fly back to France. 

" A dream that keeps on coming up in my mind is one that 
brings back a motor accident I had about six years ago, which 
gave me a severe nervous shock. I had, of course, entirely 
forgotten about it, except when in a motor, when I always 
thought of it. 

'• Of the fifth day I have absolutely no recollections." 



Effects of the Dream the Next Day 

As these dreams are nearly all of a terrifying or horrify- 
ing nature, and connected with the emotion of fear and 
failure of the defensive reactions of self-preservation, the 
subjects of them awaken with a feeling of dejection and 
pallor; they have, as Shakespeare says, " Lost their fresh 
blood in the cheeks." 

A dream recorded by one officer is of psychological 
interest as showing that a dream of a successful struggle 
for life with an enemy under terrifying circumstances gave 
rise to a feeling of exhilaration on waking; whereas the 
same officer's dream of a scene that he witnessed causing 
horror gave rise to a feeling of dejection. 

These two dreams, which recurred at intervals, were 
based upon two separate experiences. The one related 
to the existence of the legless body of a Prussian that lay 
for days in front of their dug-out, and which it was highly 
dangerous, as it was found to their cost, to remove. The 
other related to a fight with a Prussian who threw a 
bomb which just missed the man and exploded out of 
harm's way; he threw a bomb which blew the enemy's 
he^d off just as the Hun was preparing to throw another 
bomb at him. A repetition of the state of feeling that 
actually happened during life must be assumed to have 
occurred as a result of the dream. 



128 WAR NEUROSES AND SHELL SHOCK 

Analysis of Dreams with Incongruous Associations 
MAY Reveal an Emotional Association 

I could multiply instances of memories of particular 
experiences recurring in soldiers' dreams of a similar 
character to those related, and I think I have shown 
that when Shakespeare speaks of dreams born of fantasy, 
children of an idle brain, he was clearly not referring to 
the dreams of soldiers who had recently been exposed to 
all the emotional shock of battle, but to those experiences 
of past life which had been broken up and dissociated 
into elemental perceptual parts which are linked up in 
incongruous association. 

Apparently incongruous association may by careful in- 
vestigation reveal an emotional association ; thus a present 
fear experience may be associated with a past and forgotten 
fear experience, as the following dream shows : — 

An officer who had served in South Africa told me that he 
had had a dream from which he awoke in a fright. He was in 
a mine passage at the front when he met a leper who came 
towards him. Upon questioning him and asking him if he 
could recall some period of his life in which his mind had been 
disturbed by a leper, he remembered that in South Africa he 
and his comrades were much alarmed, and vigorously protested 
against a leper being allowed to remain in an adjoining sangar. 
Evidently this had left a deep impression graven on the mind ; 
the principal subject, the leper, was dissociated from concomi- 
tant experiences in the South African War, and became linked 
up with a recent terrifying experience of being in a mine 
passage, which likely enough was also an experience in which 
the emotion of fear occurred. Both incidents, suffused with 
very strong feeling, in all probability were deeply graven on 
the mind and became firmly fixed by subconscious association. 

Another case is the following, in which the dream 
appeared to have an incongruous association of dissociated 
experiences, but in which there was a natural association 
of primitive emotions. 



EMOTIONAL ASSOCIATION IN DREAMS 129 

A sergeant, who had been a schoolmaster, was asked to write 
down his dreams by Captain W. Brown, who had charge of 
my cases at the Maudsley Hospital. The first was as follo% . : — 

" I appeared to be resting on the roadside when a woman 
(unknown) called me to see her husband's (a comrade) body 
which was about to be buried. I went to a field in which was 
a pit, and near the edge four or five dead bodies. In a hand- 
cart near by was a legless body, the head of which was hidden 
from sight by a slab of stone. (He had seen a legless body, 
which was covered with a mackintosh sheet, which he removed.) 
On moving the stone I found the body alive, and the head spoke 
to me, imploring me to see that it was not buried. Burial 
party arrived, and I was myself about to be buried with legless 
body when I awoke." 

The second dream was as follows : — 

" After spending an evening with a brother (dead 11 years 
ago) I was making my way home when a violent storm com- 
pelled me to take shelter in a kind of culvert, which later 
turned into a quarry, situated between two houses. Men 
were doing blasting operations in the quarry, and whilst watch- 
ing them I saw great upheavals of rock, and eventually the 
building all around collapsed (explosion of a mine). Amongst 
the debris were several mutilated bodies, the most prominent 
of which was legless. I tried to proceed to the body, but 
found that I was myself pinned down by masonry which had 
fallen on top of me. As I struggled to get free the whole 
scene appeared to change to a huge fire, everything being 
enveloped in flames, and through the flames I could still see 
the legless body which now bore the head of my wife, who was 
calling for me. I was struggling to get free when rny mother 
seemed to be coming to my assistance, and I awoke to find the 
nurses and orderlies standing over me." 

It appears that the patient had been shouting in his sleep, 
beginning in a low voice and gradually becoming louder until 
eventually he was shrieking. The legless body occurred in all 
his dreams ; the sight of this had evidently produced a profound 
emotional shock. He had worried a great deal about his wife, 
who was much younger than himself, so that we have this 
incongruous association of the legless body and the head of his 
wife calling him ; finally, what more natural than that the mother 
should come to his help ? The emotional complex is not incon- 
gruous in this dream, for fear is linked up with the tender 
emotion. 



130 WAR NEUROSES AND SHELL SHOCK 

War Psycho-neuroses 

The psychopathology of war consists fundamentally in 
the exaggeration and perseveration of instinctive defence 
reactions incidental to normal physiological conditions, 
viz. protective pain, fatigue and emotion. This is clearly 
shown by a consideration of the somatic and psychic signs 
and symptoms of the two great groups of functional 
psycho-neuroses, hysteria and neurasthenia. 

Babinski, whose views are now widely accepted, thus 
defines hysteria, which he calls pithiatism {neiOdi, persuasion ; 
laxog, curable). 

" Hysteria is a pathological state manifested by symptoms 
which it is possible to reproduce by suggestion in certain 
subjects with a perfect exactitude, and which are susceptible 
of disappearing under the influence of persuasion (contra- 
suggestion)." 

Some authors have criticised this definition, maintaining 
that persuasion or contra-suggestion can also cure non- 
hysteric neuropathic symptoms, in particular those occur- 
ring in neurasthenia. 

Babinski remarks there is a confusion here, for it. is 
recognised that the phenomena of fatigue (essential charac- 
ters of neurasthenia) are not susceptible of cure by contra- 
suggestion; the symptoms which are made to disappear 
by persuasion are hysterical complications grafted on to 
neurasthenia. For thirty years Babinski claims that he 
has insisted upon the frequency of associations of this kind. 
The association of hysteria and neurasthenia is especially 
common in the case of soldiers who have been exposed to 
modern trench warfare. 

Dejerine thus defines neurasthenia : " Neurasthenia is 
constituted by the ensemble of phenomena which result 
from the non-adaptation of the individual to a con- 



DEFINITION OF NEURASTHENIA 131 

tinuous emotive cause and struggle of the. individual for 
this adaptation." 

Neural fatigue or nervous debility is neither neurasthenia 
nor hysteria. We may consider a condition as neuras- 
thenic if, to the phenomena of fatigue, there is superadded 
a state of continued emotivity upon which can be grafted 
obsessing preoccupation . 

Dejerine lays great stress upon the important role of 
emotion and emotivity in the genesis of psycho-neuroses, 
and a study of war psycho-neuroses confirms this opinion. 
He remarks that a great number of functional neuroses 
may be regarded as crystallisations of emotive phenomena. 

The emotion may be of internal or external origin. 
External emotive excitation creating what has been 
called emotive shock is the most frequent cause of 
hysteria. 

The points to which I wish to draw special attention, and 
which form the essence of Dejerine's definition, are continued 
emotivity and preoccupation causing a persistent neural 
exhaustion; in fact, an anxiety-neurosis. In both types 
of psycho-neurosis the constitutional factor plays a pre- 
dominant part. Neurasthenia (nervous exhaustion) with 
mental preoccupation is more likely to be acquired in 
officers of a sound mental constitution than in men of the 
ranks, because there is in the former the sense of responsi- 
bility which, in the officer worn out by prolonged stress of 
war and want of sleep, causes anxiety lest he should fail 
in his duties. He fears that his memory may fail at a 
critical moment, and anxiety weighs heavily upon him; 
mental preoccupation leads to a continued struggle to 
overcome such doubts and fears. 

Psychogenic Motor Disorders and Disabilities 

In considering the motor disorders and disabilities occur- 
ring in soldiers coming back from the front, we have to bear 



132 WAR NEUROSES AND SHELL SHOCK 

in mind that an organic lesion may be accompanied by a 
large halo of functional disturbance, or an organic lesion may 
by suggestion lead to a functional paralysis, contracture, or 
other motor disturbance. It is, therefore, essential to inquire 
carefully into the history of the onset of the motor disability. 
For it may be found that the subject had suffered with 
commotion or concussion of the skull or of the spine, and 
that this was followed by a paralysis of organic origin, but 
although the organic condition may have cleared up, yet the 
patient remains paralysed as the result of auto-suggestion. 
Many cases of this kind have occurred in my practice. 

Again, a patient may have an injury of a limb from a 
gunshot wound, necessitating the use of a splint, and when 
this is taken off, the limb is left in a state of functional 
paralysis. Or, a man is blown up and falls on his shoulder, 
his side, or his spine, and he develops in consequence a 
brachial monoplegia, a hemiplegia or paraplegia of func- 
tional origin. But we must be sure that there is not some 
organic lesion, especially of a joint or of the spine, to cause 
a contracture or paralysis. For instance, shrapnel wounds 
and other injuries may set up reflex irritation, and an 
antalgic attitude may be assumed which becomes a fixed 
habit. 

Before, howevei:, discussing in detail the hysterical 
paralyses and contractures, it is necessary to call attention 
to the fact that Babinski and Froment prefer to keep the 
term functional for those motor disorders which can be 
cured by psychotherapy, and they put in a special category 
reflex contractures and paralysis arising in consequence 
of a wound or traumatism, which without showing the 
characteristics of motor organic disease are to be distin- 
guished from functional disorders by the absolute inefficacy 
of physio-psychotherapy. They state, moreover, that these 
reflex disorders may be distinguised from hysteria by 
the following signs: (1) Vaso-motor disturbances, often 
occupying the whole of the affected limb or a segment of 



PARALYSES AND CONTRACTURES 133 

it, e. g., cyanosis, blue markings, salmon-red coloration. 
(2) Local hypothermia of a more intense degree than in 
hysteria. (3) Muscular atrophy, " moist " skin, sometimes 
even of a macerated appearance ; rarefaction of the bones 
revealed by X-ray examination ; muscular hypotonus at 
the level of certain articulations; mechanical hyper- 
excitability of the muscles corresponding to modifications 
of electrical excitability; the disappearance of the con- 
tracture in profound anaesthesia ; and in deep anaesthesia, 
after the extinction of all the other reflexes, a clonus of the 
patella can be induced in the affected leg. 

Sollier attributes most of the disorders following slight 
wounds or injuries to Charcot's classical hysteria, and sees 
in them the confirmation of his theories in the physio- 
logical origin of hysteria. He attributes great importance 
to kinsesthetic disturbances, particularly to the disturb- 
ances in the deep sensibility of joints. I have found 
that cases of intractable functional paralysis generally 
have a loss of deep sensibility in addition to cutaneous 
anaesthesia. 

Claude remarks thus : " Among the large number of 
' blesses nerveux ' who passed through the eighth region 
I have never noted these functional disorders in high- 
spirited officers who were eager to leave as soon as possible, 
nor in doctors." Non-commissioned officers and soldiers 
who showed paralysis or contractures of a particular kind 
were constitutional psychopaths and generally exhibited 
hysterical manifestations. He attributes an important 
role to the mentality of the individual in the genesis of 
the functional motor disorders which are not purely 
hysterical. 

Doubtless the psychopath by " meditation " converts 
the normal protective pain reflex into a psychogenic reflex : 
for the onset of the contracture or paralysis may not be 
immediate but may develop slowly and progressively, often 
in consequence of prolonged immobilisation of the limbs 



134 WAR NEUROSES AND SHELL SHOCK 

on a splint, or as a result of inopportune suggestion by 
daily massage and electrification by sympathetic nurses. 
With the improved treatment and morale of the French 
Army the number of cases of paralysis and contracture 
following slight injury have enormously diminished. 

The contracture may affect the upper or lower limbs. 
When the upper limbs are affected the hands assume a 
characteristic form of contracture known as " main figee " 
(congealed hand). 

What is the mechanism of these contracture disabilities 
occurring in limbs with a slight lesion ? Is it a reflex 
irritability of the motor cells of the spinal cord, or is it 
due to reflex inhibition of the motor cells presiding over 
the groups of muscles which oppose those in contracture 
which cannot be cured by physio-psychotherapy, or is it 
the result of myogenic changes ? 

Babinski assigns to the sympathetic nervous system an 
important role, and points to the vaso-motor, secretory and 
thermal disorders in support of this view. But the follow- 
ing case of Roussy, and one of my own, tend to show that 
the vaso-motor, thermal, and secretory disturbances may 
be due to hysterical immobility. 

Gustave Roussy has published a case which does not seem to 
support the reflex theory of M.M. Babinski and Froment. A 
typical case of functional paraplegia occurred suddenly in con- 
sequenc? of the bursting of a shell ; there was no wound apparent. 
No signs of an organic lesion were observed. The paraplegia was 
of the astasia-abasia type ; it was not therefore hystero-organie. 
About ten months later there existed a pronounced hypothermia 
of several degrees, with cyanosis and hyperidrosis of both feet, 
associated with disappearance of the plantar cutaneous reflex 
on one side and a great diminution on the other. 

Abolition of the plantar cutaneous reflex is disputed in 
a purely functional paralysis. Certain authors, Dejcrine, 
Sollier, and L'Hermitte, explain it by ansesthesia disturbing 
the reflex path. Others with Babinski associate it with 
hypothermia. Roussy accepts the latter explanation, for 



REFLEX PARALYSIS AND CONTRACTURES 135 

after warming the feet in this case the reflex appeared, but 
without affecting the plantar psychic anaesthesia. Even 
though there was a temporary retention of urine, this case 
was without doubt purely hysterical. He was cured by 
physio-psychotherapy in fifteen days. All the paralysis, 
the vaso-motor and secretory disturbances disappeared. 
Roussy asks, are these vaso-motor, secretory and thermal 
disorders described by Babinski therefore of reflex origin, or, 
as his case seems to show, due to hysterical immobilisation ? 
The following case which came under my notice also 
clearly demonstrates the fact that the vaso-motor, 
thermal and secretory troubles may be dependent upon 
immobility. 

An Australian private soldier was admitted to the Maudsley 
Hospital under Dr. Collier suffering with a complete flaccid 
paralysis of the right arm. He had been treated with faradism 
without success. The right arm was adducted to the trunk; 
the elbow slightly flexed ; the wrist slightly flexed ; the fingers 
and thumb were semi-flexed, and all parts of the limbs were 
voluntarily immobile. There was aero -cyanosis, hypothermia, 
sweating and insensibility of the hand. There was a large 
superficial cicatrix of a pre-war burn on the right forearm, on 
its upper and postero-external surface ; in the middle a cross 
had been tattooed. Attempts at passive movement caused 
spasm of the flexors of the forearm. He gave the following 
history : On December 19th, 1917, he had been wounded by 
shrapnel on the right forearm, in the region of the scar. He was 
for a moment dazed; after a field-dressing had been applied 
he carried on. One hour after the injury he noticed numbness 
in right arm and the numbness persisted. One week later 
he had an attack of trench fever and at the same time he 
developed (overnight) paralysis of the arm, and it had remained 
completely immobile ever since, and insensitive until he came 
under my treatment, which consisted of strong suggestion and 
exercise of associated movements — at first passive, later active. 
As the mobility of the limb returned, so the vaso-motor, secretory 
and thermal disturbances disappeared. 

He is now completely cured {vide Figs. 35, 36). 
Babinski admits that hysteria may be associated with 
these physiopathic conditions or with mental disorders. 



136 WAR NEUROSES AND SHELL SHOCK 



The following case which came under my care supports 
this in a very convincing manner. 

This man was in France from August to November 1915, 
during the latter part of which period he was nervous and 
apprehensive. From December 1915 to September 191G he 
was on liome duty because of his condition. In June 1917 he 

returned to France and when under 
fire he was paralysed with fear and 
trembled constantly. 

Li October 1917 he was blown up 
and buried. He was unconscious for 
a short time, and upon recovering he 





Fig. 35.— Condition of 
right arm before" treatment. 



Fig. 36. 



-Condition of right arm after 
treatment. 



experienced severe pain in the back. For nine weeks he was 
confined to bed with pain in back, headaches, and terrifying 
dreams. 

When he entered the Maudsley Hospital, 4th London (March 
15th), he had moderate camptocormie, walked in a stiff and 
constrained manner, with the trunk bent forward and the head 
slightly thrown back, and complained of constant pains in back, 
and headache. 

About eighty per cent, of the deformity recovered under 
faradism and persuasion ; but a residue remains. At present 



REFLEX PARALYSIS AND CONTRACTURES 137 

there is a definite spasm of the lumbar muscles, more marked 
on the left ; immobility from first lumbar down ; pain and 
limitation on hyperextension of spine ; and definite local tender- 
ness over left sacro-iliac joint. There is a zone of anaesthesia 
and analgesia in the back below the angle of the scapulae, 
which has been greatly diminished by contra-suggestion, so that 
eventually it was limited to the lower lumbar sacro-iliac regions. 
X-ray shows a pathological process involving the left sacro- 
iliac joint. 

This case shows that reflex contracture may be associated 
with a large halo of functional disorder which can be cured by 
suggestion, but there is a residuum which cannot be cured. 
Before, therefore, it is asserted that a paralysis or contrac- 
ture is wholly pithiatic we must take care to leave no stone 
unturned to show that there is no lesion which might give 
rise to reflex paralysis or contracture ; for the ascertain- 
ment of this fact is of great importance in respect to the 
award of gratuities or pensions in case we adopted the 
recommendation of the French and German neurologists 
of no home service and no gratuities for purely hysterical 
symptoms. Whereas if there is a lesion, even though it 
be slight, the disability is more difficult to cure, and in 
some cases cannot be cured by physio-psychotherapy; 
consequently the French recommend in such cases tem- 
porary auxiliary service and gratuity. 

The physiopathic organic disorders may not only be 
associated with hysterical manifestations and with nervous 
and mental disorders, but with more or less obstinate 
neurasthenic symptoms, with psychasthenic states, with 
mental confusion, and with less grave mental disorders. 
It is generally recognised, however, that hysteria and 
traumatic neurosis never determine dementia. 

It is manifest that in all the above-mentioned com- 
binations the hysterical factor is amenable to immediate 
and successful treatment, consequently all the other dis- 
orders and disabilities should alone count in all that 
concerns temporary or permanent incapacity. This, 



138 WAR NEUROSES AND SHELL SHOCK 

However, should only hold good when our doctors can all 
diagnose and treat these functional cases at the earliest 
possible moment and before they have become fixed and 
firmly installed. 

There are three stages in the development of hysterical 
paralyses and contractures : (1) An instinctive reflex defence 
reaction, often against pain, by immobilising the affected 
part. (2) The psychogenic stage in which there is persever- 
ation and exaggeration of this defence reaction. (3) Late 
phenomena of prolonged immobility, viz. wasting of muscles, 
adhesions in joints and their fixation, associated with 
vaso-motor, thermal and secretory disturbances. 



The Mental Conflict in Relation to War 
Paycho-neuroses 

The psychopathic officer is likely to be the subject of 
a continuous mental conflict. He feels deeply the responsi- 
bility which rests upon him to do his duty and put up with 
an intolerable situation. He is apprehensive lest his 
comrades should, by his actions or expression, discover 
the cause of his anxiety. He may, in consequence, become 
a danger to himself and others ; for, feeling that his com- 
rades look upon him as a coward, he may engage in a fool- 
hardy enterprise causing his own death and perhaps that 
of many of his company. If he is not killed by the enemy, 
he may become depressed and suicidal ; he may desert his 
post, or surrender to the enemy ; more often relief comes, 
by shock, emotional or commotional, followed by a psychosis 
or a psycho-neurosis. He may be wounded, in which case 
he obtains relief from an intolerable situation in the most 
satisfactory manner to his amour propre ; for the existence 
of an obvious physical disability affords him a means of 
escape from such a situation without any wound of the 
moral sense ; his mind is not tormented by the thought 
that he will be regarded as a shirker, and the mental con- 



MENTAL CONFLICT IN WAR NEUROSES 139 

flict between the concealed desire which he has had to 
escape the dangers and discomforts of trench warfare and 
the moral obhgation imposed by duty and patriotism 
ceases. When he can show a wound- stripe the anxiety 
caused by the feehng that he is regarded as a shirker 
is reheved and thus helps materially in the relief of the 
neurasthenic symptoms. Anxiety-neurosis is a far more 
common condition in officers than hysteria. In non- 
commissioned officers and men hysteria- is common. The 
more important and evident manifestations of hysteria 
are those which provide the patient with a means of escape 
from the front. These have been called by McCurdy 
conversion hysterias ; a useful term, as it represents a well- 
recognised fact that these motor and sensory disabilities 
are due to an idea being transferred into a physical symptom. 
The desire not to return to the front and the provision of 
the means of escape fixes unconsciously the idea of a dis- 
ability which originated by auto- or hetero-suggestion. 
In our conscript army the number of cases of hysteria 
has been proportionally greater than in the old professional 
army. Prolonged discipline left its mark upon the character 
and mental attitude of the professional soldier towards 
military service. The fear of punishment is greater with 
them than the fear of death in action, and prolonged 
discipline has made the professional soldier's mind highly 
suggestive to the commands of his superior officers, and 
provided his officer shows no fear he will follow him any- 
where in obedience to orders. 



Hysterical Paralyses and Contractures 

Hysterical Hemiplegia. — Hysterical hemiplegia with 
contracture or hysterical hemicontracture develops all at 
once, and is therefore not like hemiplegia of organic origin, 
which commences by a flaccid paralysis, followed later 
by a spastic condition ; moreover, neither the face nor the 



140 WAR NEUROSES AND SHELL SHOCK 

tongue are affected in hysterical hemiplegia, except in 
very rare cases. The following case, although not one of 
hemiplegia, is of interest. 




Fig. 37. — ?Fiinc(ional facial paralysis simulating Bell's palsy. All the 
mus?les were reported to respond to the. lowest conden.ser current. 
A, Normal Expression. B, Told to close both eyes. C, Told to 
smile. D, Told to frown. 



Functional Facial Paralysis Following Shell Shock and 
Burial with Hysterical Hemianalgesia 

December 26th. — Platoon mending barbed wire, and they 
were in an old German dug-out, having a drink of tea. Above 
this dug-out in which he was there was another connected by 
steps. A shell burst on the top one, and this filled the lower 



PARALYSIS AND CONTRACTURE 141 

dug-out, all but completely covering him except on the left 
side of his face, by which he was enabled to breathe. He was 
unconscious for three days ; he wanted to know where he was. 
He knew nothing of what had happened himself, and the 
above information is the result of what he was told by a 
comrade who had not been buried but had his arm blown off. 
He was in Le Treport Hospital over three weeksj and then 
sent to England and placed in the Suffolk Hospital, Bury 
St. Edmunds, from January 27th to March 9th; sent to con- 
valescent home from March 9th to June 9th, then transferred 
to 4th London. He has been seen by a great number of 
doctors at Le Treport, and they found the same condition that 
I found. His face has not changed. He has been X-rayed 
without result. He remembers going into the dug-out, and 
he hears in his 'mind the shell coming. He has terrifying 
dreams of his experience at the front. 

He has been seen by Capt. Clayton, who finds that all the 
jnuscles of the face on both sides respond to the lowest condenser. 
The expression : the left eye is prominent, the inner canthus 
is wider than natural, tears do not run into the lachrymal 
ducts. Pupils equal, react to light and accommodation. 
Conjunctival reflex absent on left side. There is absence of 
wrinkles over forehead of left side, and a lack of expression. 
When asked to frowai the left frontal region becomes wrinkled. 
The right eyebrow is at a higher level than the left. On being 
asked to show his teeth, the left side of mouth is only half 
opened. When asked to give a graceful smile, a response 
is only on the right side, where there is a dimple, and the 
risorial muscles act well ; on the left there is a blank. On 
being told to blow out his cheeks, the right side is effective, 
the left not. He complains that he has loss of sensibility of 
the tongue on the left side, also of the lips and cheeks, and he 
cannot taste on that side, and he has to press out the food 
which gets between the cheek and the jaw. He hears a tuning- 
fork, and there is no deafness in either ear. The tongue when 
protruded deviates to the right, but he can move it about to 
either side. He says his mouth is dry on the left side. 

There is a complete hemianalgesia to pricking, and a thermo- 
anaesthesia of the left half of the body. He feels a prick of 
the left side of the urethral orifice as well as upon the right. 
He asserts he does not feel on the left half of the body any- 
where, but he stated that he felt pricking on the lower half 
of the left side of the abdomen. The abdominal reflexes were 
easily obtained. There is no loss of power or wasting of the 
muscles of the trunk and limbs. The deep reflexes are normal. 
The plantar reflex on the left side is not easily obtained, and 



142 WAR NEUROSES AND SHELL SHOCK 

is mainly flexor of the small toes, with but little movement 
of big toe. He feels the vibrating tuning-fork all over right 
side, but says he does not feel it on the left. He hears it at a 
distance of a few inches from left ear, but at ten inches from 
right ear. He does not hear it over left forehead, but faintly 
over left malar bone; whether this may be associated with 
the fact that hearing on left ear is deficient as compared with 
the right is a possible reason. 

On turning him round several times and with his eyes shut, 
he feels giddy, and would fall to the right. No Romberg 
symptom. No nystagmus. The result of Capt. Clayton's 
examination shows that there is no nerve lesion now. The 
only explanation I can offer is that this case was one of a 
functional perseveration of an original Bell's Palsy. Unfortu- 
nately I have been unable to follow up this case further. 

There are two forms of hysterical hemiplegia : in one 
there is an intense contracture of the upper and lower 
limbs, the lower limb is in extension and the foot in a 
position of talipes equino-vUrus, the whole limb being 
absolutely rigid; the upper limb may assume a flexed 
position or one of extension; in either case there is a 
rigid contracture. The other form is characterised by a 
flaccid paralysis of the upper limb, which hangs quite 
inert by the side of the body. The gait is unlike that of 
organic hemiplegia; there is no circumduction of the 
paralysed leg, which is dragged forward without raising 
the sole of the foot from the ground. Hysterical con- 
tracture of a limb is marked by its intensity, the joints being 
firmly immobilised, so that the whole limb is rigid. Although 
the contracture may be overcome by sudden application 
of. force, the limb immediately returns to its former posi- 
tion wiien the force ceases. This contracture is very 
difficult to simulate by voluntary action without the 
manifestation of expenditure of great effort, as shown by 
the facial expression, irregularity of movement, and by 
the respiration. Hysterical hemiplegia is rarely met with 
as a result of a wound. 

A diffuse amyotrophy of the muscles occurs in all old 



PARALYSIS AND CONTRACTURE 143 

hysterical hemiplegias; the electrical excitability, both 
faradic and galvanic, is retained, although it may be 
diminished ; there is, however, no reaction of degeneration. 
A muscular tremor resembling the waving of a field of 
corn in the wind may occasionally be seen when the cool 
air excites the skin; but, according to Pierre Marie, this 
may be seen also in organic hemiplegia. Vaso-motor dis- 
turbances, lowering of the surface temperature, cyanosis 
of the paralysed extremities, hyperidrosis and oedema may 
be found, but they are the result of prolonged functional 
inactivity and immobility. The fact that these vaso- 
motor troubles disappear rapidly when the patient is cured 
of the paralysis by electro-psychotherapy is a proof of 
their functional origin. 



Hysteric Monoplegias and Paraplegia 

Brachial Monoplegia. — There are two types of brachial 
monoplegia, the flaccid and the spastic, the former being 
more common. In the flaccid type the paralysis is more 
complete, no movement being possible, the upper limb 
swinging like a flail at the side of the body and falling 
inertly when the patient displaces it with the sound limb. 
The shoulder is lowered, the forearm remains in passive 
extension; the hand also is extended with the fingers 
straight and abducted, and the patient is incapable of 
executing the most simple movement. A case of this 
type was recently sent to me for treatment by the Pensions 
Board. He was wounded by shrapnel at Loos, for which 
he underwent an operation. There are two linear scars 
on the left upper forearm ; the limb hangs like a flail at 
his side {vide Fig. 38). He says that he lost the use of it 
soon after he was wounded. All the muscles of the shoulder, 
arm, forearm and hand are wasted, but respond to a fairly 
strong faradic current. From the elbow to the apex of 
the limb there is a complete loss of superficial and deep 



144 WAR NEUROSES AND SHELL SHOCK 

sensibility. Above the elbow both forms of sensibility 
are diminished. He has completely lost joint and bone 
sensibility in the wrist and hand, and he does not feel 
the priek of a needle nor the strongest faradic current in 




Fig. 38a.— The photograph shows the complete immobility of the whole 
limb. It will be observed that the scars of the wound, which would 
be hardly visible had they not been painted to show their position, 
could not possibly account by a nerve lesion for the paralysis of the 
shoulder muscles. 

the hand and forearm. The hand was at first cold and 
blue, but with daily massage, electricity and passive move- 
ments both the acrocyanosis and the muscular atrophy have 
greatly improved. In spite of the improvement in the 



PARALYSIS AND CONTRACTURE 



145 



Fig. 38b. 
Pensioner, wounded at the Aisne in 
1914. Sear at entrance of bullet three 
inches below spinous process at outer edge 
of scapula. A large linear scar from left 
sterno clavicular articulation to middle of 
deltoid. The bullet penetrated the lung 
and was removed. Seven months in hos- 
pital, arm immobilised. Discharged from 
the Service, and pensioned since. Com- 
plete functional paralysis of left arm. 
Adduction of shoulder. Slight flexion of 
elbow. Flexion and pronation of wrist. 
Flexion of metacarpals and phalanges. 
General wasting of muscles. Fixation of 
joints. No loss of superficial or deep 
sensibility. All muscles respond to Fara- 
dism. The skin of the palm of the hand 
is macerated and sore with the mark of 
the nails. An X-ray examination which 
I have had made showed a fracture of 
the neck of the scapula. 





Fig. .38c. — After a month's treatment he is able to use his arm and hand ; 
he can use a fork and can grasp objects. He has continued to improve 
since the photograph was taken. 



146 WAR NEUROSES AND SHELL SHOCK 

muscles, he is unable to perform any movement of the 
apcesthete limb. We must suppose that owing to the 
length of time the limb has been inert and apcesthete a 
cortical dissociation of the sensory representation of this 
portion of the ego has been firmly installed and organised. 
Before the will can operate upon a part of the body con- 
sciousness of its existence and relative position of its parts 
are essential. It is somewhat similar to a functional 
deaf-mutism. This may be contrasted w4th another case 
of brachial monoplegia following a gunshot wound in 
1914. The bullet passed through the left scapula at its 
border and lodged in the front of the chest below the 
clavicle ; it was removed. There is a long scar beneath 
the left clavicle ; there is wasting of the whole of the 
muscles of the limb, particularly of the deltoid; there is 
a paralysis of the arm, the wrist is flexed, and the fingers 
and thumb flexed in the palm {vide Fig. 38b). There is no 
loss of sensibility. Whereas the patient with the apces- 
thete limb after six weeks' treatment has shown not the 
slightest sign of voluntary movement, although the muscles 
have developed well, the patient with no loss of sensibility 
after a few days' treatment has begun to move the fingers 
and wrist, and overcome the flexor contraction by exten- 
sion {vide Fig. 38, b and c). 

In the flexor type of contracture the forearm is more or 
less flexed upon the arm in both varieties of conjbracture ; 
the fingers are flexed upon the palm, sometimes accom- 
panied by flexion of the wrist {vide Figs. 39, 40). The 
closed fist with extension of the wrist is much rarer. 

In contradistinction to contractures from an organic 
cause, every attempt to move the limb is without effect 
and may only exaggerate the intensity of the contrac- 
ture. The application of an Esmarck bandage, which, 
as Brissaud has shown, causes organic contractures to 
cease, exaggerates functional contractures or makes no 
difference. 



PARALYSIS AND CONTRACTURE 



147 




Fig. 30. — Functional hemiplegia with 
semiflexion of wrist and fingers, 
cured by physio-psychotherapy. 



Fig. 40. — Functional brachial mono- 
plegia with paralysis of extensors 
of wrist and fingers, cured by physio- 
psychotherapy. 




B 



Fig. 41. — A, Functional right brachi 
monoplegia. 



B, Cured by physio-psychotherapy. 
Figures 39 and 41 are photographs of officers suffering with hysterical paralyses. 



148 WAR NEUROSES AND SHELL SHOCK 

Crural Monoplegia. — This form of monoplegia is less 
frequently met with than the brachial. There are two 
types, the flaceid and the spastic; the former is very 
seldom seen and is very rarely complete : the patient 
always remains capable of executing some voluntary 
movement and is able to walk with the aid of crutches or 
sticks. During the automatic movement of walking with 
crutches, muscles are seen to contract which remain 




Fig. 42. — Functional contracture with extension and talipes equino varus 
of long standing, cured by physio-psychotherapy. 

immobile when the patient is lying down. In the case of 
contracture of the lower limb the usual attitude is that of 
forced extension with equinism of the foot, sometimes 
excessive, accompanied by plantar flexion of the toes. 
Usually the foot takes the position of talipes equino-varus, 
at other times a tahpes with an excessive flexion of toes 
may occur. Contracture in extension is the rule {vide 
Fig. 42). 

Crural monoplegia with contracture is one of the com- 
monest forms of war psycho-neurosis. 

The Flexor Type. — The leg is flexed incompletely upon 



PARALYSIS AND CONTRACTURE 



149 



the thigh and the thigh upon the pelvis; the foot rests 
upon the ground by the anterior extremity. Both active 
and passive movements are extremely limited, and only 
by employing great force is it possible to correct the 
vicious position. The gait is painful, slow, and charac- 
terised by a particular form of lameness. This type is 
comparatively seldom seen. The more common type is 
the following. 

The Extensor Type. — Inasmuch 
as the leg is absolutely straight in 
extensor contracture, progression is 
only possible by an elevation of the 
pelvis on the affected side, which is 
necessarily accompanied by a curva- 
ture of the spine with the convexity 
directed away from the sound side. 
The foot is not always in a condition 
of extension, but may be immobilised 
in the normal position. In such a 
case walking is easier, because the 
sole of the foot rests upon the 
ground, but the toes are usually 
extended; moreover, since there is 
no tilting of the pelvis, the com- 
pensatory spinal curvature is not 
necessary. The patient is able to 
walk by dragging the foot along the ground. 

Paraplegia. — This is the commonest type of paralysis 
met with in war psycho-neuroses. There are two types, 
the flaccid and spastic. In the flaccid form the lower 
limbs remain extended and immobile while the patient is 
lying in bed ; he is unable to move them or even to make 
a single muscle contract. All passive movements are 
made with the greatest of ease. It is only by the aid of 
the upper limbs and crutches that the patient is able to 
get about ; as he swings himself along it may be noticed 




Fig. 43. — Case of long- 
standing functional 
paraplegia, cured by 
physio - psychothe- 
rapy. 



150 WAR NEUROSES AND SHELL SHOCK 

that the paralysed limbs execute movements, albeit with 
but little strength; also that certain muscles which were 
incapable of contracting voluntarily when the patient is 
lying in bed on his back, may be observed to contract 
during progression with crutches {vide Fig. 43). 

Spastic Paraplegia. — The only type is that of rigid 
extension and adduction, causing the knees to touch and 
to cross one another; the feet participate in the con- 



FiG. 44. — Case of functional spastic paraplegia, vit/c tlic scissor-like position 
of the legs in walking, cured by physio-psychotherapy. 

tracture and tend to take on the form of talipes equino- 
varus {vide Fig. 44). 



Contractures of the Trunk 

Contractures of the trunk muscles are of common 
occurrence, and have appeared almost as a new type of 
contracture since the war. The form most commonly 
met with is a curvature of the trunk forwards, so that 
the man stands and walks Avith his trunk bent forward 
and head more or less thrown back, usually supporting 
himself with a stick in either hand, the thighs are rotated 
outwards, and there is abduction of the feet. The French 



HYSTERICAL CONTRACTURES OF TRUNK 151 

term this condition "plicature" or " camptocormie " {vide 
Figs. 45, A, B, c). It frequently arises in consequence of 
a man being blown up by an exploding shell or mine; 
it is not due to an organic lesion, but is a functional 
psychomotor contracture brought about usually in the 
following manner. When the patient recovers from the 
unconscious or dazed state caused by the explosion, 
which may have led to contusion of the lower part of 



mm 

i i 




Fig. 45. — A, Case of functional cvirvature of spine (camptocormie). 
B, Improved by treatment. C, Cured. 



the spine by burial in a trench or dug-out, he finds 
that to assume the erect position causes him pain. The 
pain in the first instance causes an instinctive protective 
reflex to immobilise the injured part which the will is 
powerless (and from a psychological point of view should 
be powerless) to overcome. But if this protective re- 
action persists, evacuation follows, and with it arises 
the fulfilment of a wish to escape from an intolerable 
situation, the effect of which is to reinforce consciously 
and unconsciously the idea of pain if the erect posture 
were assumed. The normal pain reflex is thus trans- 



152 WAR NEUROSES AND SHELL SHOCK 

formed into a psychogenic reflex and a vicious circle is 
eventually established; for the persistence of the con- 
tracture may actually cause pain by stretching of the 
ligaments, which, reacting upon consciousness, still further 
inhibits will power to make endeavours to overcome the 
disability. Certainly these patients with pseudo-spondy- 
litis do not remain in this vicious attitude because pain 
is thereby relieved, for if they continue to suffer pain it 
is by reason of the fact that the vertebral ligaments are 
stretched by the abnormal position of the trunk ; and the 
proof of this is that, as soon as the subjects of this affec- 
tion are cured by physio-psychotherapy, the pain in the 
lumbar region disappears. 



Functional Paralysis or Contracture of a Circum- 
scribed Region of the Hands, the Feet, the 
Shoulder, the Trunk and the Neck 

Functional paralysis of one hand or both hands, one 
foot or both feet, may be rarely met with. 

In the hand the paralysis is absolute and generally 
flaccid, consequently there is wrist drop ; there is inability 
to flex the fingers, the thumb alone being capable of per- 
forming any movements, and these are limited. The skin 
of the hand and forearm is usually analgesic. 

When the foot is paralysed there is foot drop and the 
sole is slightly turned inwards, as in talipes equino-varus. 
There is a complete loss of voluntary movement; all 
passive movements are, however, possible. 

Vaso-motor disturbances and disuse atrophy of muscles 
may come on, together with some alterations of electrical 
reactions. 

Various contractures of the hands and feet may occur. 
The hand contracture may take on the following forms : 
the hand of the accoucheur is the most frequent type of 



CONTRACTURE AND PARALYSIS 



153 



hysterical aero -contracture. The fingers are in close con- 
tact with one another in extension, the first phalanges 
slightly flexed, the thumb extended and adducted, and 




Fic. 41). — Accoucheur hand, gunshot wound of arm afrecting the inediau 
nerve. Area of superficial anaesthesia shown. There was a complete 
loss of deep sensibility in the thumb. The fingers and thumb could be 
forcibly separated, but immediately returned to the former position. 
A fibrillary spasm was observed in the muscles of the thumb when 
it was extended. Under chloroform anaesthesia {vide Fig.) the con- 
tracture only partially disappeared. 

its palmar surface opposing the index finger {vide Fig. 46). 
As a general rule passive movements are impossible on 
account of the rigid contracture of the muscles. 

There are other forms of contracture : (1) the fingers 




Fig. 47. — Functional paralysis of hand in consequence of superficial bum of 
hand, five months' duration. The joints of the fingers and wrist had 
become fixed in extension owing to the splint applied. After breaking 
down the adhesions he was able to separate the fingers and flex them. 



are extended and closely approximated, the thumb ex- 
tended but not adducted into the palm {vide Fig. 47) 
{main en benitier) ; (2) the fingers_]^closely approximated. 



154 WAR NEUROSES AND SHELL SHOCK 

the phalangeal joints extended, the mctacarpo-phalangeal 
joints flexed {main en tiiile); (3) the fingers and thumb 
approximated, with flexion of the fingers at the metacarpo- 
phalangeal joints, and the wrist like the beak and head of a 
bird ; (4) it may resemble the contracture due to a lesion of 
the ulnar nerve, but without the extreme wasting of muscle 
{vide Fig. 48); (5) the fingers are approximated closely 
and semiflexed at all the joints, the thumb is adducted. 




Fig. 48. — Functional main en 'jriffc simulating an ulnar paralysis, 
cured by physio-psychotherapy. 

the palm is hollow as when the hand is used as a drinking 
cup {vide Fig. 49). 

Talipes equino-varus is^ the form usually met with in 
contracture of the foot {vide Fig. 42). 

The evolution of the acro-contracture of psycho-neurotic 
origin is not so unfavourable as the paralysis. If these 
contractures are not treated, but allowed to persist for 
some time, relaxation of ligaments and deformities of the 
articular and osseous structures occur. 

Contracture of the Calf Muscles. — ^A remarkable 
case came under my notice. A soldier Avas in a transport 
which was torpedoed in the Mediterranean; he was four 



DISABILITIES OF GAIT AND STATION 155 

hours in the water, which was very cold. He suffered with 
a contracture of the gastrocnemius and soleus muscles of 
the right leg, which had persisted for a year, and which 
he attributed to a cramp in the leg at the time. Some 
authorities thought it was a reflex spasm, but no cause 
could be found, and it was completely relaxed under 
chloroform. Also it could be partially relaxed by forced 
continuous dorsal flexion of the foot. 

Pains are caused by dragging on the nerves and tendons 




Fig. 49. — Functional paralysis of hand, cured by 
physio-psychotherapy. 

in contractures, especially when passive movements are 
undertaken to correct the deformity. If the contracture 
is not cured, deformity in vicious positions occurs with 
organic changes in the structures involved. 

Various other contractures of one or several muscles or 
groups of muscles may occur. Thus there may be torti- 
collis due to contracture of the sternomastoid and trapezius 
muscles, and contracture of the muscles causing retraction 
of the neck, simulating thereby meningitis. 



Disorders and Disabilities of Gait and Station 

Ataxia may occur in the subjects of neurasthenia or 
hysteria; in the former the ataxia resembles cerebellar 



156 WAR NEUROSES AND SHELL SHOCK 

disease. The symptoms are inco-ordination, vertigo, un- 
certainty in walking and oscillation of the body, but the 
disorder of gait and station never attains the same in- 
tensity as in cerebellar disease. In hysteria the ataxy 
may resemble any form of ataxy due to organic disease, 
and spino-cerebral or even bulbo-pontine conditions may 
be simulated. 

Astasia-Abasia. — Charcot distinguished two principal 
forms: (1) paralytic astasia-abasia ; (2) ataxic astasia- 
abasia, which may be either choreiform or trepidant. 
Both varieties are frequently met with in cases of shell 
shock, whether the shock be commotional or emotional. 
The characteristic sign of this functional disability is the 
fact that the patient lying in bed can voluntarily execute 
all movements of the lower limbs, although he is unable 
to stand or walk. 

Paralytic Astasia-Abasia. — The inability to stand or 
walk varies in degree of intensity in different cases. In 
some cases it is absolutely impossible for the patient to rise 
from the chair, or much less to hold himself up and walk. 
When the attempt is njade the thighs are immediately 
flexed upon the pelvis, the legs upon the thighs, and the 
patient falls down on the ground if he is not held up 
under the arms. It seems as if he had forgotten how to 
stand or walk. In other cases the disability is less pro- 
nounced. The patient can still rise from the bed or chair 
and stand up, but the moment he tries to walk the feet 
seem glued to the ground, and each foot is only raised from 
the ground with great difficulty. Nevertheless, the patient 
lying in bed can perform all movements with energy and 
without difficulty. 

Sensibility is generally intact, and there is no loss of 
muscular sense or sense of position in the limbs; the 
functional disability cannot thus be accounted for. 

In some cases the difficulty in walking only occurs after 
the patient has taken a few steps, then the knees give way 



DISABILITIES OF GAIT AND STATION 157 






B C 

Fig. 50. — A, Ataxic astasia -abasia. B, Improvement. C, Cured. 



and he is no longer able to advance, and if he does not sit 
down he will fall. This latter condition is really due to 
fear that he will fall down — staso-basophobia — and is not 
an uncommon condition. 

Ataxic Astasia-Abasia is a condition sometimes seen in 
which it is observed that the moment the patient puts his 



158 WAR NEUROSES AND SHELL SHOCK 

feet on the ground the lower Hmbs become agitated by 
inco-ordinate, irregular, violent movements which make 
it difficult for him to maintain his balance. Even if he is 
held up under his arms and tries to walk with this sup- 
port the muscles of the legs and thighs become suddenly 
thrown into successively rapid movements of flexion and 
extension {vide Figs. 50, a, b, c). This form of astasia- 
abasia is sometimes called choreiform; it is also unat- 
tended by sensory disorders. The upper limbs are not 
affected in this functional motor disability of astasia- 
abasia. Cases occur in which a man is able to make 
progression, although owing to the jerky inco-ordination 
the walking may resemble dancing or look as if the man 
were on wire springs. Occasionally cases are seen in which 
progression is made by little jumps. One patient under 
my care would take a few steps and then break into a 
rapid double shuffle of his feet upon the ground, making 
but little actual progression. This case is described on 
p. 165. 

These various forms of motor disabilities have morbid 
characters in common, and are of the same patho- 
genesis. 

Treatment. — They may be cured by contra-suggestion, 
viz. persuasion accompanied by faradism and followed by 
re-education, as in the case of paralysis of functional 
origin, except that they are, generally speaking, more 
difficult to cure. 



Tremors, Tics, and Choreiform Movements 

It has already been shown that the signs and symptoms 
of the war psycho-neuroses may be regarded as a per- 
severation of two physiological conditions, viz. emotion and 
fatigue. This general principle underlying the symptoma- 
tology of the functional neuroses affecting soldiers returned 



TREMORS, TICS, CHOREIFORM MOVEMENTS 159 

from the front is well illustrated in the case of tremors, 
tics and choreiform movements. 

The emotion of fear plays an all-important part in the 
production of general tremor. In a heavy bombardment, 
not only soldiers who are fresh to trench warfare as well 
as constitutional psychopaths are seized with a general 
trembling of the whole body as a result of the emotion of 
tear, but even experienced soldiers, who have become 
emotive on account of prolonged stress, may be similarly 
affected. The crouching attitude of immobility for con- 
cealment is associated with a general muscular inertia, 
pallor of the skin, sweating and coldness owing to the blood 
being withdrawn from the superficial parts of the body 
to the internal structures. The tremor, therefore, may 
be partly due to a general reaction of shivering from cold 
increased in many cases by exposure to wet and cold. A 
perseveration of the trembling may therefore occur to- 
gether with the secretory (sweating) and circulatory 
(tachycardia acro-cyanosis) disturbances. The initial 
physiological emotional reactions are transformed into a 
psychogenic reaction {vide p. 133) by the unconscious 
fulfilment of a wish. Likewise many of the tics are the 
result of perseveration of the startling and dodging reflexes, 
and some of the choreiform movements which I have seen 
seem to be due to perseveration of gesture movements of 
horror. 

Generalised tremors and quaking are amongst the most 
objective signs of war psycho-neurosis ; according to Roth- 
feld, they are always due to defective innervation and an 
involuntary spread of nervous impulses to antagonistic 
groups of muscles, and this defect is of high central 
origin. 

The Tremors. — The tremors may be divided into two 
classes : (1) those which resemble in the frequency, rhythm 
and amplitude of the oscillations the tremors occurring in 
certain recognised diseases. (2) A typical tremor which 



160 WAR NEUROSES AND SHELL SHOCK 

does not correspond to the tremors of disease but rather to 
the tremblings and quakings of fear. This form of tremor 
is seen in cases of shell shock; it may come on when 
consciousness returns, but hours or days may elapse before 
it appears; it may affect the whole body or parts of it, 
especially the limbs and head. 

In severe cases of shell shock the patient may lie or sit 
curled up, the head bent on chest, the arms fixed to the side 
and flexed at the elbows and wrist, the thighs flexed on the 
trunk and the legs on the thighs, and in this attitude all 
the flexor muscles may be continuously in a state of 
more or less rapid contraction and relaxation. This 
tremor may persist for a long time, as the following case 
illustrates. 

A gunner who was blown up by a 17-inch shell in the 
early part of the war, and came under my care six months 
after the shock, was then in the state above described. 
After tareful examination and repeated assurances that he 
would recover, he was completely cured. 

The whole body, one half of the body, both legs, both 
arms, or a single arm or leg may be the seat of tremor. 
Its psychogenic origin is shown by its disappearance under 
the influence of electro-psychotherapy. 

An unconscious (hysterical) atypical tremor is often 
consciously exaggerated, and it is difficult to decide whether 
such a tremor is wholly voluntary or only exaggerated. 

Emotional tremor is variable in its amplitude, its fre- 
quency and duration, and tends usually to disappear some 
days or weeks after the emotional shock, especially if the 
trembler is closely watched and subjected to electro- 
psychotherapeutic treatment. But emotional disturb- 
ance or apprehension will bring back the tremor, especially 
when these soldiers are exposed to the terrors of an air 
raid. 

The tremors which resemble those of definite diseases 
are : (1) fine, (2) coarse, (3) intentional. 



TREMORS, TICS, CHOREIFORM MOVEMENTS 161 

The fine vibratory rhythmical tremor (9-10 per sec.) 
of neurasthenia is similar to the tremor of Grave's disease ; 
it forms part of the neurasthenic syndrome, and may be 
regarded as one of the signs of neural exhaustion. It is 
best recognised in the separated fingers of the outstretched 
hand ; and it is made more evident by laying a thin sheet 
of paper on the hand, which is then thrown into rapid 
vibration. Many cases of shell-shock neurasthenia also 
show a fibrillary tremor of the orbicularis palpebrarum 
when the eyelids are closed, and some exhibit tremor in 
the orbicularis oris. Two serious diseases show tremor 
of a similar character, especially in the lips and tongue, 
causing alterations in the speech, viz. chronic alcoholism 
and general paralysis. But attention to the other signs 
and symptoms of chronic intoxication in the former, and 
to the signs, clinical and pathological, of syphilitic organic 
brain disease [vide p. 173) in the latter, will enable a 
diagnosis to be made in a case which is complicated by one 
of these morbid states. In about 10 per cent, of the cases 
of shell-shock neurasthenia there are signs of a mild or 
moderate hyperthyroidism, viz. fine tremor, dilated pupils, 
some degree of exophthalmos, von Graefe's sign, Moebius's 
sign, tachycardia, palpable thyroid, and in some instances 
sweating of the upper lip and root of the nose. Senile 
tremor of old age need not be considered here. Another 
form of tremor which is coarser and less rapid than the 
preceding, viz. 5-6 per sec, is that which resembles paralysis 
agitans; but the age of the soldier, the absence of the 
characteristic signs of this disease, viz. the mask-like ex- 
pression, the gait and the rigidity of the muscles, together 
with its curability by treatment, exclude the diagnosis of 
Parkinson's disease. 

The intentional tremor of disseminated sclerosis may 
be simulated by hysteria; as a rule, however, the oscilla- 
tions are of greater amplitude at the root of the limbs in 
the former, whereas in hysteria, it is the hand which is 



162 WAR NEUROSES AND SHELL SHOCK 

most affected. Some of the following signs of organic 
disease, such as nystagmus, staccato speech, changes in 
the fundus oculi, and a plantar extensor response, will be 
present among other characteristic signs of disseminated 
sclerosis and serve for the differential diagnosis from war 
psycho-neurosis. 

Any form of tremor may be simulated by the hysteric, 
and, from some experiments which have been made in my 
laboratory, it appears that any form of tremor may be 
simulated voluntarily, even the fine vibratory tremor of 
the neurasthenic. 

The test, however, of voluntary tremor is inability con- 
stantly to maintain the rhythmical oscillations of the same 
amplitude and rapidity for any length of time, or while the 
attention is diverted, or in one hand while the other is 
engaged in performing another and totally different opera- 
tion. Still, the practised malingerer can often maintain 
a tremor for a long time ; generally, however, he overacts 
the part, and when his attention is diverted or he imagines 
he is unobserved the tremor ceases or varies considerably 
in the amplitude and the rapidity of the oscillations. 

According to Ruhemann, a fine intentional tremor of 
the feet cannot be simulated, and he regards the same as 
a proof of a functional nervous disorder. The tremor o/ 
the feet is not observed when the patient is at rest, but 
first appears when the leg is raised. For the investigation 
of this tremor the knee should be slightly extended and 
the toes pointed. The tremor usually shows oscillatory 
movements of flexion-extension, whilst small ranged lateral 
tremors are less frequently observed, but equally character- 
istic. The tremor is sometimes made more definite by 
Jendrassik's method of reinforcement. The diminution or 
disappearance of this tremor affords a useful indication of 
the course of the disease. This fine tremor of neurasthenia 
cannot be removed by physio-psychotherapy, but the coarse, 
quaking hysterical tremor associated with pseudo-spastic 



TREMORS, TICS, CHOREIFORM MOVEMENTS 163 

paresis can be readily cured by faradism and suggestion, 
vide pp. 272-286. 

Tics.^ — One of the commonest forms of tic is a clonic spasm 
causing a lateral movement of the head as if to avoid a 
projectile. This is spoken of as the " dodging reflex." Tics 
characterised by clonic spasms are much more commonly 
met with than those due to tonic spasm. Clonic contrac- 
tures of the neck or of the head producing movements 
indicating affirmation or negation, elevation of one or both 




Fig. 51. — Blepharospasm following conjunctivitis 
caused by Mustard Gas. 

shoulders, unilateral or clonic unilateral or bilateral facial 
movements are variations of spasmodic tics. 

Another spasm that is common is blepharospasm ; this 
may occur as a result of a blinding flash of an explosion 
or by the earth or sand being blown into the eyes ; it may 
happen in consequence of irritating gases exciting a reflex 
contraction, by which a habit spasm is installed {vide 
Fig. 51). These functional tics are readily cured by per- 
suasion {vide Figs. 52, a, b), but they are apt to return 
when the individual suffers with fatigue or emotional 
shock. 

Purposive habit spasms may be produced by shell shock, 



164 WAR NEUROSES AND SHELL SHOCK 

and they occur whenever the patient is excited by a noise — 
the " startled reflex." Thus, I had under my care a sergeant 
who had been a very successful heavy-weight champion 
pugilist ; he had been sent home on account of shell shock 
after Loos. He was doing well at another hospital, when 
a Zeppelin raid occurred ; this brought on an attack of 
motor excitement for which he was sent to the 4th London 
General Hospital. The motor agitation took the form of 
continuous jerking, defensive, purposive movements of 





Fia. 52. — A, Functional facial spasm and tortieollis. B, Improved 
by physio-psychotherapy. Eventually cured. 



the head and shoulders as if to avoid a blow, compression 
of the lips and facial grimaces, such as, no doubt, he as- 
sumed when fighting. This habit spasm was accompanied 
by jerky upward movements of the head and eyes, and in 
broken utterance the word Zepp. The clonic spasms per- 
sisted for months, especially observable when a noise 
excited him; even the click of billiard balls irritated him 
to such a degree that he would, although a peaceable and 
good-tempered man, show resentment against the game 
continuing. 

The spasmodic tics can often be shown to be a stereo- 



TREMORS, TICS, CHOREIFORM MOVEMENTS 165 

typism of a reflex defensive movement. Thus an officer 
had a continuous backward movement of the head ; he told 
me that it came on after his aeroplane had crashed to the 
ground nose downwards. When the 'plane hit the ground 
he threw his head back. 

A common spasmodic tic is a lateral movement of the 
head and a dropping of the shoulder. An interesting 
example that this is of the nature of a persistent defence 
movement, doubtless made continuous by the combined 
effect on the subconscious mind of hearing shells coming, 
is afforded by the following case : A soldier who was 
partially deaf in the left ear, caused by a shell bursting 
on that side, had a lateral spasmodic tic of the head to the 
right with a dropping of the left shoulder — the " dodging 
reflex " made persistent. I stood on his left side and 
unawares clapped my hands forcibly so as to produce a 
loud noise ; the defensive reaction was the dodging reflex 
accompanied by pushing away with the left hand and flight 
to the right. At the same time the patient became flushed, 
agitated and evinced a pained, anxious expression. 

Another interesting example of the stereotypism of a 
spasmodic movement was afforded by a youth, who when 
walking, after a few normal steps, broke into a rapid series 
of short shuffling steps in which the feet were hardly raised 
from the ground. It appears that the youth had an 
hysterical convulsive seizure in a trench as a result of a 
shell bursting near. This " double shuflle " was a part of 
the convulsive seizure, for when the youth was hypnotised 
he would go through the whole performance again that 
occurred when the shell burst. If he were seated on a 
couch, his eyes kept closed and told that he was going to 
sleep, he would very soon fall off the couch to the right, 
turn over on his face, and then would follow rapid convulsive 
movements of the arms and legs, something of the nature 
of running away. 

Choreiform Movements. — These are not uncommon, 



166 WAR NEUROSES AND SHELL SHOCK 

although in several eases whieh have come under my care 
there was a history of chorea in earlier life; in the majority 
of cases the irregular jerky movements of the limbs, the 
head, the neck, and the facial muscles have come on after 
the shell shock. Thus a young lieutenant was admitted 
suffering with an acute choreiform condition and a 
marked anterograde and retrograde amnesia. Months 
elapsed before the choreiform movements ceased, in spite 
of persuasive psychotherapy; he was troubled for a long 
time with terrifying dreams, and his memory was almost 
a blank for the whole time he was in France ; he had some 
weakness of the left leg, the opposite side to the bruise on 
the forehead. X-rays showed no signs of fracture, but 
the history of the case clearly pointed to concussion, and 
probably some vascular and meningeal haemorrhages had 
occurred, which together with the commotion accounted 
for the chorea and the other profound symptoms caused 
by shock. 

Another case is of interest from several points of view : 

Captain J , age twenty, was admitted December 18th, 

1915, exhibiting a purposive motor delirium like that of a man 
suffering with terrifying hallucinations ; thus he sat up in bed 
muttering continuously, moving his head and body from side 
to side, stretching out first one hand and then the other as if 
pushing away some hateful object, alternating this movement 
by that of passing his hand across the forehead. There appeared 
to be a perseveration of the gestures of horror. When, how- 
ever, his mind was diverted by conversation he would answer 
questions rationally and the movements would become quieter, 
although his utterances remained jerky and hesitant. It was 
ascertained that he had not lost consciousness when the shell 
exploded near him, but that he had received a terrible emotional 
shock. A piece of exploded shell had knocked off the head of 
a brother officer while he was talking to him, scattering blood 
and brains over his face. It was ascertained that he had 
suffered with chorea in early life, for this fact appeared in his 
Medical Sheet ; inasmuch as the nature of his disease was stated 
to be chorea, the Pensions Board regarded the case as one of 
recurrent chorea and refused to grant any compensation. 
Eminent physicians who had seen him in France confirmed the 



DIAGNOSIS OF PARALYSES, CONTRACTURES 167 

opinion I expressed, that this was not another attack of chorea, 
but choreiform movements brought about by shock; accord- 
ingly he received a liberal gratuity. This officer even after a 
year had not recovered emotional stability, and finally had to 
be boarded out as permanently unfit. 



The Diagnosis of Hysterical Paralyses and 
Contractures 

Since hysteria can simulate almost all forms of disease 
of the nervous system, it is always safer to approach the 
diagnosis of hysteria by exclusion; moreover, it cannot 
be too strongly insisted upon how frequent a functional 
motor or sensory disability may be combined with organic 
disease of the nervous system or with other affections, e.g., 
of internal organs. 

The hysterical patient will very probably give a history 
pointing to a constitutional neuropathic tendency. The 
history of the onset of the attack is of importance in the 
diagnosis. In functional paralyses or contractures the 
onset is sudden and complete and may appear immediately 
after the patient has recovered consciousness or after 
a period of meditation. The differential diagnosis of 
hysterical convulsive crises, which may be followed by 
or associated with mutism, deafness, paralyses or con- 
tractures is considered on p. 211. 

In hemiplegia due to organic disease " flaccid paralysis," 
due to the effect of diaschisis, precedes the spastic condi- 
tion ; in functional paralysis of the flaccid type it remains 
flaccid and the spastic remains spastic. 

Babinski has introduced the following valuable tests 
for the differential diagnosis of organic from functional 
hemiplegia. 

(a) " Seize the paralysed arm, raise it, then allow it to 
fall, repeat several times this operation, each time attract- 
ing the patient's attention by talking to him. If you 
exercise a little patience in repeating the operation it will 



168 WAR NEUROSES AND SHELL SHOCK 

be noticed that in the case of hysteria the arm will remain 
in position, without any support, for some little time; the 
paralysis has disappeared temporarily. This never happens 
in the case of organic hemiplegia." 

(b) The tendon and osseous reflexes form part of a group 
of objective phenomena which the will is incapable of 
modifying; for this reason they are of the greatest im- 
portance in the differential diagnosis of the psycho-neuroses, 
simulation and organic disease, and to Babinski is due the 
credit of pointing out new methods of investigation of 
the reflexes, which we cannot do better than summarise. 

The plantar extensor sign of Babinski may be described 
best in his own words. 

1. "In general it is not only by the direction of the 
movement that the normal reflex differs from the patho- 
logical ; more often extension is executed with more 
slowness than flexion ; moreover, flexion is usually stronger 
when the internal part of the sole of the foot is excited 
than when the excitation is applied to the external, and 
the converse for that which concerns extension ; finally, 
whilst flexion predominates in the two or three last toes, 
it is in the first or first two toes that extension is ordinarily 
most pronounced. 

2. " The phenomena of the toes may present itself in 
early forms ; that is to say, the plantar reflex may exhibit 
characters partly pathological, partly physiological. For 
example, in certain subjects the excitation of the sole of the 
foot provokes extension of the great toe or of the two first 
toes, and gives place at the same time to a flexion of the 
last toes ; in others the toes are extended when the external 
parts of the sole is excited, yet in others whatever part 
of the sole is excited the plantar reflex is manifested some- 
times by flexion, sometimes by extension of the toes; 
in the latter the first excitations generally yield flexion." 

The technique is thus explained by Babinski. 

" The muscles of the foot and leg must not be in a state 
of contraction, and it is well to tell the patient to look at 
the ceiling or to shut the eyes. The leg should be slightly 
flexed upon the thigh, and the foot should not rest upon 



REFLEXES IN DIAGNOSIS OF HYSTERIA 169 

the bed by its external border, or be deprived of all support 
by the observer raising the leg. When the museles appear 
to be relaxed the excitation of the sole can be made. The 
sole may be excited by stroking or pricking. The latter is 
necessary in some subjects in order to obtain a reflex 
movement of the toes. The excitation of the sole of the 
foot sometimes provokes a reflex abduction (fanning) of 
the toes. Both these signs point to an organic lesion 
causing degeneration of the pyramidal tracts." 

In hemiplegia of organic origin Babinski has described 
a number of signs. Besides the above-mentioned signs 
of the toe, which occur on the paralysed side, are a number 
of other signs which serve to differentiate organic hemi- 
plegia from functional, viz. — 

1. Muscular hypotonicity, which may be thus demon- 
strated in the upper limb — 

" If the forearm be placed in supination and a passive 
movement of it be made by flexion upon the arm, the two 
segments of the Hmb, forearm and upper arm can be 
approximated much more upon the paralysed than the 
non-paralysed side; this is termed exaggerated flexion of 
forearm upon arm." 

2. Sign of the platysma — 

" If the patient is made to open his mouth as widely as 
possible, sometimes when he flexes strongly the neck, the 
platysma muscle comes into view by longitudinal folds of 
the skin; these are not seen on the paralysed side." 

3. Combined movement of flexions of the thigh and of 
the trunk in organic hemiplegia — 

" The patient is made to lie quite flat on his back and 
told to fold his arms and raise himself, the paralysed limb 
is flexed at the hip and the heel is raised from the bed, 
whilst the opposite limb remains immobile, or is only 
slowly raised and less high ; at the same time the shoulder 
of the normal side is carried forward." 



170 WAR NEUROSES AND SHELL SHOCK 

4. Grip of the hand — 

" If one glides the hand between the fingers and the 
palm of the paralysed patient and at the same time 
attempts to place it in a condition of extension, a resist- 
ence is experienced which gives the impression of an 
obstacle endowed with elasticity and sometimes animated 
by a slight trepidation. Moreover, whilst the hand is 
extended upon the forearm, the phalanges are flexed upon 
one another and upon the metacarpals and squeeze the 
hand of the observer. Babinski remarks that this gives 
rise to a characteristic ensemble of different perceptions 
to the observer that occur in organic hemiplegia as a rule, 
but never in hysterical hemiplegia." 

5. Sign of pronation; this can be obtained in organic 
hemiplegia before even contracture is established. 

" The patient is told to allow the upper limbs to be 
quite inert, then the forearms are placed in a position of 
supination ; they are supported at the wrist by their dorsal 
surface and several squeezes made; the hand of the 
hemiplegia side becomes pronated." 

A useful sign of organic disease is that of Oppenheim — 

" In the normal condition when deep friction of the inner 
side of the leg below the knee is made, either there is no 
reflex of the toes or there is a plantar flexion. In cases of 
organic spastic hemiplegia or paraplegia, extension of the 
toes often occurs." 

It must be remembered that a spurious ankle clonus 
often occurs in hysteria, and all the deep reflexes may be 
exaggerated. Again, the abdominal reflexes may not be 
obtainable when there is much fat in the abdominal walls. 

The sensory disturbances do not correspond to any 
spinal segmental or peripheral nerve distributions. 

When either anaesthesia or analgesia exist the sensory 
disturbance often affects one half of the body and is, 
according to Babinski, the result of suggestion by the 



DIFFERENTIAL DIAGNOSIS OF HYSTERIA 171 

method employed in testing sensibility. It does not exist 
in the meatus urinarius. 

A stocking or gauntlet anaesthesia of the limbs is indica- 
tive of a functional sensory disturbance. 

As the sensory disturbances are the result of suggestion, 
they are curable by contra-suggestion. 

An important diagnostic sign is the response to treat- 
ment of functional cases, for should a cure not be obtained 
by electricity and persuasion, the patient is very possibly 
an exaggerator or simulator. When slight signs of organic 
disease are found, e. g., the plantar extensor response, 
fanning of the toes, and Oppenheim's sign, together with 
absence of the abdominal reflexes associated with normal 
skin sensibility, the diagnosis of an organic lesion causing 
pyramidal tract degeneration is justified, although the 
paralysis, if absolute, may be mainly (if not entirely) of 
functional origin. 

Long-standing cases of functional paraplegia with vaso- 
motor, thermic, and secretory disturbances associated with 
disuse, atrophy of muscles and anaesthesia, following im- 
mediately shell shock and persisting for more than a year, 
may, to those unacquainted with such cases, be regarded 
as due to organic commotional lesions of the spinal cord 
of an hystero-organic nature. The sphincters are not 
paralysed. The muscles may be wasted in the paralysed 
limb, but they react normally to the galvanic and faradic 
currents. The plantar cutaneous reflexes may be abolished 
in such cases, and yet the condition is one of functional 
paraplegia. Dejerine, Sollier and others explain the 
abolition of the cutaneous reflex by anaesthesia disturbing 
the reflex path. Other authorities, including Babinski, 
explain the absence of the plantar reflex by the hypo- 
thermia. I have seen several cases of this kind. 



172 WAR NEUROSES AND SHELL SHOCK 

Differential Diagnosis of Peripheral Neuritis and 
Hysterical Paralysis 

Generally speaking the diagnosis is easy. In neuritis 
there is (1) a diminution or abolition of the bone and tendon 
reflexes. (2) Muscular atrophy. (3) Complete or partial 
reaction of degeneration. (4) Hypotonicity of muscles. 
(5) The exclusive localisation of the motor disability and 
degenerative atrophy as well as disturbance of sensibility 
to areas corresponding to the anatomical distribution of 
one or several nerves. 

Late Tetanus and Reflex Contracture 

The following are the points given by Babinski for the 
recognition of localised tetanic contracture — 

1. This contracture is intense; it cannot be modified 
by passive movements without causing acute pain, and it 
is difficult to modify it. 

2. Paroxysmal extremely painful localised muscular 
spasms resembling those observed in normal tetanus. The 
cramp is sometimes preceded by pain in the scar of the 
wound. 

3. Late tetanic contracture does not last more than two 
or three months. 



Diagnosis of Functional and Organic Disease 

The differential diagnosis of functional paralysis and 
contractures from paralysis and contractures due to organic 
disease, whether caused by concussion of the head or 
spine, or as a result of morbid processes, is not difTicult, 
if a systematic examination is made. It is first necessary 
to point out that a paralysis or contracture associated 
with a slight lesion may ndt yield to treatment by physio- 



FUNCTIONAL AND ORGANIC DISEASE 173 

psychotherapy. But h it necessary to assume with 
Babinski that the disability is due to spinal reflex action ? 
May it not be explained by the wound acting as a 
constant source of suggestion of the idea of paralysis or 
contracture ? 

A gunshot wound of the head may cause a depressed 
fracture of the skull, or a penetrating wound with destruc- 
tion of brain substance. If the lesion is on the same side 
as the paralysis or contracture it may be assumed that it 
has nothing to do with the paralysis or contracture of limbs 
of the opposite side; neither has it probably any con- 
nection with it, if the lesion is not in the region of the 
motor area. If it is in the motor area and affects only a 
portion of it, then it is unlikely that it will give rise to a 
complete and permanent hemiplegia affecting arm and leg. 
There may, however, be a monoplegia of either the leg or 
arm associated with a functional paralysis of the other 
limb. 

Organic disease arising from arterial embolism or throm- 
bosis, especially the latter, and due to syphilitic arteritis 
may occur, and, unless a careful physical examination be 
made, be mistaken for a functional condition with disastrous 
results. I have even seen a monoplegia due to cerebral 
tumour sent back with a diagnosis of functional mono- 
plegia, and its treatment by hypnosis and suggestion 
attempted. It is only right to state, however, that only 
very few cases are sent over with a diagnosis of functional 
neurosis that are afterwards shown to be organic in origin. 
Early cases of general paralysis are sometimes sent over 
with a diagnosis of neurasthenia or shell shock, and occa- 
sionally cases are diagnosed as general paralysis upon 
clinical evidence, which upon further observation and ex- 
amination of the blood and cerebro- spinal fluid are found 
not to be suffering with this organic disease. A few 
cases of amyotrophic lateral sclerosis, syringo-myelia and 
disseminated sclerosis are met with, and in most instances 



174 WAR NEUROSES AND SHELL SHOCK 

these organic diseases have been correctly diagnosed. One 
difficulty which occasionally presents itself is the existence 
of miner's nystagmus, and this, associated with spurious 
clonus, exaggerated deep reflexes, and a functional paralysis 
and coarse tremor has led to the diagnosis of disseminated 
sclerosis. I always make it a rule to ask the occupation 
in cases of nystagmus, and when I find the patient is a 
miner I regard the cause of this symptom as being in all 
probability due to his occupation. Cases of tabes are 
occasionally seen; upon inquiry I have found a few 
instances in which men have been admitted to the army 
when suffering with lightning pains and girdle sensation ; 
presumably these patients had at the time the charac- 
teristic pupil phenomena, although they were in the pre- 
ataxic stage. Such cases show the importance of examining 
the pupils in every case ; for experience tells us how very 
rare it is not to find some pupil phenomena in syphilitic 
disease of the central nervous system, especially in tabes 
and general paralysis. 

Gunshot wounds of the spine (including pieces of high- 
explosive shells or shrapnel) may without penetrating the 
theca vertebralis cause a focal haemato-myelia ; if this 
occurs in the cervical region a paraplegia may result with 
paralysis of the arms and wasting with R.D. of the muscles 
supplied by the cervical region of the cord. There is not 
much difficulty in deciding the organic nature of the 
paralysis in such cases. But occasionally a bullet may 
fracture a transverse process of a cervical vertebra, as in 
the following case. A machine-gun bullet fractured the 
transverse process of the seventh cervical vertebra ; the 
patient was admitted with paralysis of the right arm and 
hand with loss of sensibility of the ulnar side of the hand 
and some wasting of the small muscles of the hand. 
There was also paralysis of the right leg with plantar 
extensor response. Recovery of power occurred both in 
the arm and leg after a short time. The extensor response 



FUNCTIONAL AND ORGANIC DISEASE 175 

and some spasticity of the leg remained, indicating that 
there had been a contusion and degeneration of the pyra- 
midal tract on that side. Later an aneurism of the common 
carotid occurred, and the artery was ligatured on the 
proximal side; a few days later the patient suffered with 
a pain in the head arid a dazed condition, and this was 
followed the next day by a complete left-sided transitory 
hemiplegia. I presume a non-infective clot escaped into 
the anterior branch of the right middle cerebral artery, 
but as the arteries of the brain were healthy and the clot 
was non-infective, collateral circulation was restored, for 
the hemiplegia passed off and the young man was dis- 
charged some weeks later to his home. I have been 
unable to find out the subsequent history of this case. 

Concussion of the spine (without visible injury) from 
the explosion of a large shell in a dug-out or other closed 
space causing haemato-myelia is not infrequent {vide 
pp. 54-57), but attention to the physical signs and the 
history of the onset and its causation enables a correct 
diagnosis to be made. Occasionally, however, a man may 
have a large halo of functional paralysis superadded either 
to this condition or to that arising from gunshot wound. 
A man who has recovered from organic spastic paraplegia 
sufficiently to walk and stand without aid may from 
emotional shock suddenly lose the use of his legs, and 
the question naturally arises : Is this due to a lighting up 
of the old organic trouble, or is it purely functional ? 

Spinal rachialgia with curvature of functional origin 
(the French plicature or camptocormie) may arise as a 
result of spinal concussion, and the differential diagnosis 
of this from organic disease, from Pott's disease, and 
from concussion haemato-mvelia has to be made. 



176 WAR NEUROSES AND SHELL SHOCK 

The Diagnosis of Contractures and Paralysis of 
Limbs following Injuries and Wounds 

Contractures and paralyses arising as a result of wounds 
and injuries fall into three principal groups : — 

(1) The paralysis or contracture entirely of functional 
origin, coming on immediately after the injury or after a 
short period of meditation ; the wound serves as a con- 
stant source of suggestion of paralysis or contracture, and 
this is reinforced and firmly installed in the mind by 
immobilisation and disuse, till after a time arthritic and 
myogenic changes occur {vide Case, and Fig. 36). 

(2) The paralysis or contracture is partially organic and 
due to injury of a nerve, but there is a large halo of func- 
tional disability which can, like (1), be cured by physio- 
psycho therapy {vide Fig. 46). 

(3) The paralysis and contracture* is entirely due to 
the nerve lesion {vide Fig. 53). 

To make a differential diagnosis of the above three 
conditions a history of the injury and how it was subse- 
quently treated should be ascertained, and for this purpose 
answers to the following questions should be obtained : — 

(1) How. soon after the injury did the present paralysis 
or contracture arise ? 

(2) Was it accompanied with loss of sensibility, and if 
so, what parts were insensitive ? 

(3) Has the paralysis or contracture extended or 
diminished since the injury? 

(4) Was any operation performed for removal of the 
projectile, and was the nerve divided and sutured ? 

(5) Was the limb long immobilized on a splint ? 

(6) Did the patient suffer with tetanus and receive 
antitoxin injection? This should be asked in localised 
painful contracture following wounds. 



CONTRACTURE AND PARALYSIS 



177 



Examination of Patient 

An investigation of the wounds or cicatrices, their size, 
probable depth, situation and anatomical relation to nerves, 
should be noted. The scar of entry and exit of penetrating 
wounds should be considered in relation to the probable 
course of the projectile and the damage caused to anatomical 
structures. An X-ray picture may be necessary to ascer- 




FiG. 53. — Ulnar paralysis following shrapnel wound of inner side of fore- 
arm. A little dark swelling painful neuroma is seen about the middle. 
The dark patch (painted) on the hand marks the anaesthetic area. 
The characteristic wasting of the small muscles of the hand and 
hyperflexion contraction of the ring and little fingers is seen ; this 
is due to the fact that the ulnar supplies the two outer lumbricales 
muscles which are paralysed. The result is that the long flexors 
overcome the extensors more completely than in the case of the 
two other fingers, the lumbricales of which are svipplied by the 
median. 

tain whether the disability is in any way due to injury of 
joints or fracture of bones, or if there are fragments of 
metal left in the tissues, serving as a cause of irritation of 
a nerve. Voluntary and passive movements of the joints 
are to be tested ; the latter may be done with the patient's 
eyes shut, telling him to repeat all the movements with 
the sound limb. The deep and superficial sensibility is 
tested. A gauntlet or stocking anaesthesia with a lof>s of 
the kinaesthetic and deep sensibility in a case of paralysis 
or contracture is indicative of a functional condition {vide 
Fig. 36). 

If a plexus, for example the brachial or its cords, a 

N 



178 WAR NEUROSES AND SHELL SHOCK 

peripheral nerve such as the musculo-spiral, median, or 
ulnar, be injured, an anatomically characteristic paralysis 
and deformity will result, with a corresponding anatomically 
characteristic sensory anaesthesia {vide Areas of Sensory 
Nerve Distribution, Appendix). The deformity is due to 
atrophy of groups of muscles supplied by the injured nerve, 
and consequent overaction of opposing groups of muscles. 
The paralysis and atrophy is limited to the muscles supplied 
by the injured nerve {vide Table, p. 176), and these muscles 
either give the reaction of degeneration or fail to respond 
to Faradism or the condensor— unlike the muscles wasted 
from disuse, which respond to both normally. A know- 
ledge of the motor points {vide Appendix) is necessary to 
test the electrical reactions of muscles, but the best method 
of testing the functional activity of a muscle is the physio- 
logical, which consists in feeling whether a muscle contracts 
when a person is told to perform a definite movement. A 
paralysis or contracture in excess of that which can be 
explained by the anatomical nervous supply of muscles is 
psychogenic in origin, or due to prolonged immobility with 
consequent arthritic and muscular changes. 

Psychopathic Sensory Disturbances and 
Disabilities 
The functional sensory psychopathic disturbances fall 
into two great groups. 

1. Subjective. This group includes all those numerous 
and varied hysterical simulations of painful diseases of 
organs and structures arising from a " fixed idea " of pain 
localised or generalised in the body. 

2. Objective. This group includes the functional anaes- 
thesias, hypaethesias, analgesias, hypalgesias and hyper- 
sesthesias affecting a more or less extensive surface of the 
body. It also includes the loss of deep sensibility, viz. the 
kinaesthetic sense of joints, muscles, tendons, and the bone 
sense of vibration. 



PSYCHOPATHIC SENSORY DISABILITIES 179 

The Psychopathic Sensory Disabilities 

Since every structure and organ of the body is repre- 
sented in the field of consciousness constituting the ego, 
it follows that if an " idea " of pain in a localised region 
is planted in the mind the idea tends to cause a conscious 
voluntary or involuntary reaction of defence. In recruits, 
conscripts and soldiers on active service, the conscious or 
subconscious wish to escape from an intolerable situation 
is fulfilled by an incapacitating localised pain which may 
arise by auto- or hetero-suggestion. The mind voluntarily 
or involuntarily responds to the pain by a defensive 
reaction, then by repercussion in the field of consciousness 
a vicious circle is established and a " fixed idea " of pain 
of central origin is installed. That the subconscious desire 
to escape from an intolerable situation is the essential 
cause of many of these topoalgias is shown by the fre- 
quency with which the lower limbs are affected by painful 
incapacitating conditions simulating organic diseases, such 
as sciatica, coxalgia, rachialgia and neuritis. 

As the pain causing the disability is subjective, the 
difficulty always arises of deciding whether pain really 
exists at all, and whether the reaction disability is a 
voluntary simulation or not. 

In judging whether there is conscious voluntary simula- 
tion or exaggeration we have to be guided by past conduct 
and present motives. Whereas the hysteric who is an 
unconscious simulator welcomes, even revels in, a thorough 
examination, the malingerer generally loathes it, and if 
the examination is searching he becomes resentful, sulky 
and complaining. The hysteric by his conduct shows that 
he is, in a great measure, unconscious of the unreality of his 
symptoms ; the malingerer, on the other hand, conscious of 
the unreality of his symptoms, is suspicious and ill at ease. 

In estimating the genuineness of pain without causal 
objective signs the facial expression should be watched, 



180 WAR NEUROSES AND SHELL SHOCK 

the presence of local changes noted and alterations in 
attitude observed, remembering that the malingerer nearly 
always overacts his part. Finally, general or local dis- 
turbances of nutrition should be looked for. 

The many and varied algias may arise apparently 
spontaneously as a subconscious " wish " fulfilment, or in 
consequence of suggestion in the form of a slight injury, 
such as a fall, a blow or a wound. Again, inoculation, 
rheumatism, fever and trench feet may by suggestion 
become the basis of a " fixed idea " of pain with a corre- 
sponding defence reaction, and thereby a means of escape 
from military service. 

A soldier at the front may receive a slight shrapnel or 
gunshot wound, or be blown up by a shell, causing a 
contusion of the spine or of one of the large joints; and 
his attention is concentrated oh the injured part by the 
pain. This pain persists as an " idea " in fulfilment of 
a conscious or subconscious wish to be sent to the base 
(vide p. 133). 

Pseudo-Arthritis. — In the upper limb the shoulder is 
the joint most frequently complained of as being painful 
on movement; the elbow and wrist seldom. The joints 
of the lower extremity are the most often complained of, 
especially the hip, giving rise to a pseudo-coxalgia. The 
sacro-iliac joint is not infrequently the seat of pain. 
Radiography usually shows no affection of the joint, but 
sometimes the symptoms have been suggested by a pre- 
vious organic lesion. The treatment which in the past 
has been adopted for this trouble has fixed in the mind 
the idea of an incurable disease. 

Spinal rachialgia is not at all uncommon; the pain is 
diffuse and not localised, and the whole spine is tender, 
more or less; the patient, open to suggestion, can easily 
be induced to shift the painful spot. Thus, I had a man 
who said he was unable to walk because of the pain in 
the spine. I sat behind him and told him to tell me the 



PSYCHOPATHIC SENSORY DISABILITIES 181 

exact spot where he felt the pain; he locaUsed it at the 
end of the spine. I said to an officer who was with me : 
" He is four inches below the end of the spinal cord." 
I then talked to him upon another matter and again 
tried, and he had shifted the painful spot four inches 
higher. I again suggested that it was too low : "It 
should be between the shoulder blades." Again, after a 
little while, he accommodated the painful spot to my sug- 
gestion. I then told him that there was nothing wrong 
with the spine and he had better get up, put away his 
sticks and walk; which he did. 

As a rule the pains in these psycho-sensory algias do not 
conform to segmental root distribution {vide Table, p 176), 
nor to the course and anatomical distribution of peripheral 
nerves {vide Sensory Nerve Areas, Appendix) ; they are 
not found at points of emergence of nerves from bones; 
the pains are mobile, and particularly open to change 
of situation by suggestion; they rapidly disappear with 
electro-psychotherapy. 

The Anaesthesias, Analgesias, Hyperaesthesias 

The objective alterations of sensibility in the war 
psycho-neuroses are much less important than those of 
subjective sensibility. They do not cause any functional 
disability, in fact the patient is unaware of the existence 
of any sensory disturbance until it is suggested by exami- 
nation; they are therefore not a cause of evacuation; 
they are usually associated with some motor functional 
disability, such as hemiplegia, other varieties of paralysis, 
tremors and convulsive hysterical crises, and they are 
discovered during the course of examination. Loss of 
sensibility to pricking or touch tested by cotton wool may 
extend over extensive areas of the body ; thus there may 
be a stocking anaesthesia of the legs or gauntlet anaesthesia 
of upper limbs. There may be a complete hemianaesthesia, 
but pricking of the urethral orifice elicits pain on both 



182 WAR NEUROSES AND SHELL SHOCK 

sides. The cutaneous reflexes are present and normal. 
All these objective sensory disturbances are due either to 
auto-suggestion or hetero-suggestion, generally by the 
doctor, who tests cutaneous sensibility by asking the 
patient if he feels the prick of a needle. This suggests to 
the patient that he is not expected to feel. As Babinski 
points out, the proper method of testing is to make the 
patient point, with his eyes shut, to the spot pricked or 
touched. All these sensory symptoms in the hysteric can 
generally be removed at one sitting by the faradic brush 
and counter-suggestion. 

Loss of Bone Sensibility and of the Kinsesthetic 

Sense 
In many cases of hysterical paralysis there is a loss of 
sense of movement and of position of the joints. This 
may be tested by telling the patient to close his eyes and 
follow in the sound limb the changes of position made by 
passive movements of the paralysed limb. The bone 
sensibility is tested by the vibrating tuning-fork placed 
upon the bones. The sensibility of the bones to this 
stimulus is lost in conjunction with the loss of the kin- 
aesthetic sense. The muscles nevertheless, although atro- 
phied by disuse, respond to faradism {vide Case, p. 145). 

Reflex Reaction in Relation to Hysteria and 
Malingering 
The cutaneous reflexes are diminished or abolished 
according to the presence of anaesthesia or hypaesthesia 
(Oppenheim). According to Chavigny, in the majority of 
instances of hysterical anaesthesia the " tickling " reflexes 
(when these reflexes originate in the anaesthetic areas) are 
abolished, whereas reflexes termed organic are still retained 
in spite of anaesthesia at their " starting-point." It has 
been stated that malingerers, as evidence of anaesthesia, 
are able to suppress the plantar reflex of one side, or with 



PSYCHO-SENSORIAL AFFECTIONS 183 

the same end in view exaggerate the reflexes on the oppo- 
site side. Moreover, according to Teissier, a dissociation 
of reflexes may occur in hysteria, viz. aboHtion of the 
plantar with exaggeration of the patellar reflex. It is 
well known that Babinski's sign is one of real importance 
in the detection of organic disease as opposed to functional. 
But it is well to point out that if all the toes are extended 
no inference can be drawn with certainty; also that a 
simulator by practice can (upon gentle stroking of the 
plantar surface of the ball of the great toe and internal 
half of the heel) produce dorsal extension of the great toe. 

Psycho-Sensorial Affections 

Never before have the special senses of sight and hear- 
ing in vast numbers of human beings been subjected to 
the same intense and prolonged excitation accompanied 
by emotional disturbances, especially in the case of hearing, 
as during this war. 

A man was sent down from the clearing station on February 
10th, 1916; he had been blown up and buried; he was blind, 
deaf, and mute. He was sent from the St. John Ambulance 
Hospital, France, to the 4th London, and admitted on February 
29th. When I saw him he was lying in bed on his side, with 
his legs curled up. He took no notice of any sounds however 
loud, he did not speak, and he could not see. This was the 
condition noted when in hospital in France. When I examined 
him he could be made to open his eyes, and it was found that 
the pupils reacted to light ; he took no notice of a strong light, 
nor did he reflexly close the eyes when a blow was suddenly 
aimed at the face. The slightest touch on the face, however, 
aroused an immediate defensive movement or withdrawal of 
the part. It was difficult to test the reflexes, but I failed to 
obtain any deep reflexes of the lower extremity, and I could 
not obtain a plantar response. I saw him fed with milk; at 
first he resented the nozzle of the feeder touching his lips, but 
as soon as the milk entered his mouth he swallowed it. I 
understand there has been no difficulty in feeding him. He 
responds to the calls of nature, and does not wet the bed. 
He is even more sensitive and apprehensive to touch than the 
deaf-mute, who also showed fear of being injured when touched. 



184 WAR NEUROSES AND SHELL SHOCK 

The next day wh'le suffering from the pain of an enema, which 
was relieving the bowels, he somewhat suddenly regained his 
sight. He looked around in a bewildered manner, then burst 
into tears. The next day he was able to WTite. His powers 
of recognition were good, but he had a complete gap in his 
memory of the whole time he was in France. With the recovery 
of sight the skin hypera^sthesia disappeared. There was still a 
bewildered blank expression of the countenance, but he was 
able to tell us where his home was, how many brothers and 
sisters he had, their names and ages, as well as other informa- 
tion except his experiences in France, Two days later he had 
a sort of hysterical fit and recovered his speech and hearing. 
The next day I saw him he greeted me with a happy expres- 
sion of the face, and I congratulated him upon his recovery. 
He was able to converse upon most subjects, but there was 
still a complete loss of power of recollection of all that had 
happened in France. 

This blind deaf-mute, then, was for a time conscious of the 
external world only by tactile and kiuciesthetic perceptual im- 
pressions, consequently the mind was focussed on them in his 
life of external relation. Owing to the effect of past terrifying 
experiences constantly revived in dreams and very possibly, 
being blind, by hallucinations, his mind was constantly suffused 
with fear and apprehension of danger, hence the protective 
reactions of withdrawal of a part touched were greatly 
exaggerated. 

" Severe Shell Shock." Functional Deaf-mutism following 
Bar any Experiment ; " Terrifying Dreams " ,• Pantomime 
of Bayoneting in Sleep ; Sudden Recovery of Hearing and 
Speech, with Severe Mental Disturbance. 

A deaf-mute was admitted under my care; he displayed 
extreme apprehension of being touched in any part of his 
body. Although quite unable to hear any sound or produce 
any audible sound, he was able to write a lucid account of his 
experiences. He to d me that he was at Ga lipoli, and that 
while in the trenches a big shell fired by one of our monitors 
fell short into the trench he was in, and he lost consciousness. 
When he came to, he was neither deaf nor speechless, but in 
the Canadian hospital the doctors had syringed his ears with 
hot and cold water, and he became deaf and dumb. This 
man had terrifying dreams of trench warfare; he had had a 
slight wound of the right arm, which he continually felt, and 
he was most apprehensive of being touched on it or any part 
of his body. Captain Brown, at my request, hypnotised him, 



, PSYCHO-SENSORIAL AFFECTIONS 185 

but it did not restore his hearing and speech. I suggested 
that his speech would come back to him on a certain day, 
and, although this did not happen yet he began to whisper the 
vowel sounds and whisper words of one syllable. I assured 
him it would come back, and every day he greeted me with 
the thumbs up. During the several months this man has 
been in the hospital, he has on many occasions been observed 
to sit up in bed, look under the bed, first on one side, then 
on the other, then perform the pantomime of bayoneting the 
enemy. Of this he has no recollection. On March 10th he 
had a kind of hysterical fit, and Dr. Ash, in the absence of 
Captain Brown, was summoned. A little later it was found that 
he could both hear and speak. I saw him the next day; he 
greeted me with a joyful face and thanked me. Curiously, he 
had lost his recollection of having written down that he had 
lost his speech after the treatment in the hospital, and he said 
he remembered nothing about the incident, although he told 
us again that the monitor had dropped a shell in the trench 
that he was in. All the hyperaesthesia had now disappeared; 
he no longer instinctively shrank away from being touched. 

It is remarkable to note that these two cases illustrate 
in an extreme degree, in the form of an hysterical fit, the 
mental shock that often precedes or accompanies the 
restoration of the functions of hearing and speech. When 
this does not happen it is not uncommon to find the 
patient complaining of headache or dizziness following or 
preceding the restoration of function. 

It is not surprising, therefore, to find deafness and 
deaf-mutism appearing as a result of shell shock. Less 
frequent, but still not very infrequent, are the cases of 
blindness, and occasionally both senses are lost. These 
psycho-sensorial affections were almost unknown before 
the war; likewise mutism, which has already been very 
fully considered in another chapter. Loss of taste and 
smell are very rarely met with. 

Deafness 

Deafness and deaf-mutism are a very common result of 
shell shock. They are due to a psychogenic disturbance 
causing cortical dissociation in the centres of hearing. As 



186 WAR NEUROSES AND SHELL SHOCK 

hearing is the primary incitation to speech, it is probable 
that dissociation of the auditory perceptor centres causes 
the mutism; for recovery of hearing is followed by, and 
immediately associated with, recovery of speech. The 
patient affected with psycho-sensorial deafness or blindness 
rarely shows any serious visible external injury. 

The organic lesions, caused by " windage," of the eyes 
and ear have already been discussed when considering 
commotional shock {vide pp. 74-76). But functional affec- 
tions of the special senses, especially deafness and deaf- 
mutism, form part of the clinical syndrome of shell shock 
in a considerable percentage of cases. When the patient 
recovers consciousness from shell shock and is perhaps 
wandering or sitting in a dazed condition, it is found by 
the stretcher-bearers that he does not reply to questions, 
nor can the doctor at the CCS. obtain any answer. 
Possibly, however, when taken by surprise and suddenly 
told to put out his tongue or shut his eyes, he obeys, but 
later no response is obtained. This functional deafness 
may be partial, or completely affect one ear or both ears ; 
it is more likely to occur if the man has previously suffered 
with organic disease of the ear. The patient complains of 
tinnitus in the form of banging, booming and singing in 
the ears. Unlike organic disease of the ear, the patient 
with functional deafness is able to modulate the loudness 
or pitch of the voice. I have had cases which came under 
my care who had been absolutely deaf many months and 
the disability has produced noticeable depression, which 
disappeared almost immediately after they were cured 
by physio-psychotherapy. Hysterical deafness is usuallj' 
complete to all sounds. The tuning-forks applied to the 
bone are not heard. In fact the deafness from cortical 
dissociation is absolute, and in that respect differs from 
deafness due to organic disease. 

Hyperacusis or extreme sensibility to sound is more 
common than hypoacusis; it is a very common and 



PSYCHO-SENSORIAL AFFECTIONS 187 

troublesome symptom giving rise to the " starting reflex," 
and often makes the patient suffering with shell shock 
or war neurosis apprehensive and miserable, and this 
excites and aggravates the headache. 

Vision 

The organic changes met with in ophthalmic practice 
have already been discussed on pp. 71-73. 

Shortly after shell shock the patient may complain of 
blurred vision or as if everything were seen through 
smoked glass. The blindness may come on after a period 
of " meditation," and persist, as in this case, for months. 

Sergeant L , age 29, joined in 1915. Before he was in 

the army he lost his left eye ; it had to be inucleated in con- 
sequence of an injury caused by a nail flying up into it while 
hammering. The history he gives of his loss of sight is typical. 
He is in the A.S.C., and was taking up a train with 9*2 ammu- 
nition in December 1918 when the Germans fired shells at it, 
one of them hitting the train and exploding the ammunition. 
He was blown up and picked up unconscious. He could see 
indistinctly : " everything looked hazy," After a few days 
(period of meditation) he was completely blind, except for the 
power of telling light from darkness, I'he pupil reacts very 
briskly to light and upon convergence. The fundus is normal. 
The hands are clammy; he has an anxious, worn, rather 
mask-like expression, but complains of no symptoms beyond 
his loss of vision. 

He made a complete recovery by physio-psychotherapy. 

Another case under my care was of interest. A shell 
burst near a man while he was attending to a wounded 
comrade. He managed to drag the wounded man into a 
culvert, but then found he was quite unable to see. 
Another wounded man came into the culvert and helped 
him to get out. The emotional shock was the primary 
cause of the blindness, but it did not come on till the 
darkness of the culvert suggested it. 

Failure of accommodation (asthenopia) is not infrequent 
in war neurosis, especially in neurasthenia. It may be 



188 WAR NEUROSES AND SHELL SHOCK 

weeks before the patient is able to read large print, or the 
patient is readily fatigued and the print becomes blurred. 
Macropsy and micropsy are occasionally met with. An 
instance of the former condition occurred in a Canadian 
officer under my care; he told me that the cartridges of 
his bandolier looked as large as pom-poms. Photophobia 
is common, but usually this is due to the action of irritant 
gases ; photophobia is often associated with blepharospasm 
{vide Fig. 51). Hysterical monocular diplopia occasionally 
occurs. 

Sphincter Affections 

Reference has already been made to the fact that 
retention of urine frequently follows shell shock. Incon- 
tinence of urine is a not infrequent manifestation of hysteria 
in soldiers. As a result of fear a soldier passes urine 
involuntarily, wets his breeches and wets his bed; he 
becomes an object of derision by his comrades, which 
adds to his disability ; the involuntary act becomes firmly 
installed as a habit. Nocturnal emissions which the indi- 
vidual had suffered with in early life may return in con- 
scripts, and owing to the nuisance caused to others, lead 
to their discharge. Hysterical anuria may be dismissed, 
as it does not occur. The cases which were formerly 
described are now recognised as being deceptions. 

Neurasthenic Signs and Symptoms 

Whereas hysterical signs and symptoms are common 
in soldiers and non-commissioned officers they are com- 
paratively infrequent in officers; and the great majority 
of officers invalided home for functional nervous disease 
are suffering with neurasthenia arising from various causes 
incidental to modern warfare. The signs and symptoms of 
neurasthenia from which they suffer differ in no essential 
from those which affected men in times of peace, except 
in two or three important respects, viz. (1) Prolonged 



SIGNS AND SYMPTOMS OF NEURASTHENIA 189 

stress of war with responsibility leading more often to an 
acquired condition of neurasthenia. (2) Sexual functions 
playing a far less important role in the production of 
fatigability and irritability of the nervous system. (3) 
The subconscious mind as shown by the persistent terrifying 
dreams exercising a pronounced reminiscent fear effect. 

Symptomatology. — Every organ and structure in the 
body is represented in consciousness, but happy is the 
individual who is oblivious of the functions of the organs 
of digestion, circulation and respiration ; for, if the mind 
dwells upon these organic functions, their normal automatic 
action is disturbed, discomfort and pain result, which, 
reacting back upon consciousness, add to the mental 
apprehension and a vicious circle is soon established. 

Lassitude, weariness and fatigue are protective subjective 
feelings, that own no visible objective cause, and are due in 
great measure to exhaustion of the neural elements. They 
impose a desire for rest of the mind and repose of the body, 
by which a recuperation of neural energy may take place. 

The subjective symptoms of neurasthenia are numerous 
and diverse. The objective signs are few in comparison 
and relatively unimportant. The symptoms will now be 
considered in detail. 

Headache. — This symptom is almost invariably present; 
in the early stages it is severe and constant with exacerba- 
tions ; as the patient improves in general health, particularly 
after natural sleep has returned, the headache diminishes 
in severity and constancy. The character and site of the 
pain varies in different individuals. Some complain of a 
dull aching diffuse pain, others of a splitting, bursting 
feeling or of a tight band; sometimes the pain is boring 
or lancinating. It does not necessarily affect the whole 
cranium, as it may be localised to the forehead, the temples, 
the back of the eyes, the occiput, the en casque of Charcot. 
The patients often complain of a feeling of emptiness, of 
muzziness, of fulness, of pressure, or of constriction of 



190 WAR NEUROSES AND SHELL SHOCK 

the head. After a sleepless night, or one disturbed by 
terrifying dreams, the patients complain of headache in 
the morning, which tends to pass off during the day. 
Emotional disturbances of any kind are apt to be followed 
by, or associated with, exacerbations of cephalalgia. 

Not infrequently there is hyperaesthesia of the scalp, 
and cases occur in which there is hyperaesthesia of the neck 
and stiffness, a condition which might with other symptoms 
make one suspect cerebro-spinal meningitis. 

Spinal Hyper.t^sthesia and Rachialgia. — The hyper- 
aesthesia may be localised or diffuse; the patient may 
complain of a burning sensation, of numbness and tingling 
radiating into the buttocks and down the upper part of 
the lower limbs ; he may state that he suffers with various 
sensations in the spine which, although not neuralgic in 
character, are often increased by pressure, movements of 
the spine, or prolonged standing or walking. Upon ex- 
amination of the spine no objective signs can be found, 
but sometimes over this area there may be tenderness 
on pressure. The subjective feelings may be continuous, 
intermittent or transitory. 

Associated with this spinal hyperaesthesia there may 
be a feeling of weakness or heaviness in the lower ex- 
tremities which may simulate an oncoming paraplegia, 
due to meningo-myelitis ; likewise the pain and paraesthesia 
may induce in a syphilitic the fear of locomotor-ataxy. 
Pains in the thorax may simulate pleurisy, and neuritis 
may be feared in various situations on account of these 
subjective feehngs, but there is neither tenderness on 
deep pressure of the limbs nor are the nerves painful on 
compression. 

Spinal neurasthenic symptoms I have seen much more 
frequently in recruits sent to me for an opinion than in 
soldiers and officers returned from the front. 

Insomnia. — Loss of the habit of sleep and fatigue 
conspire in producing one of the most frequent, persistent 



SIGNS AND SYMPTOMS OF NEURASTHENIA 191 

and baneful symptoms of irritable nervous weakness in 
soldiers who have been exposed to the prolonged stress of 
war. There is weariness and desire to sleep, but if the 
patient dozes off it is only to live over again the terrible 
experiences he has gone through; often he is awake till 
the early hours of the morning, or he complains of awaken- 
ing at an early hour and of being unable to fall asleep again. 
The important influence of dreams has already been fully 
discussed. 

Insomnia often leads to the habit of taking drugs to 
induce sleep ; they may be necessary, but great care 
should be taken to avoid the drug habit and endeavours 
should alwaj^s be made to restore natural sleep which alone 
can lead to recuperation of an exhausted nervous system. 

Muscular Weakness. — Not only is the neurasthenic 
patient incapable of any sustained mental effort, but bodily 
fatigue on exertion is a constant symptom. There is no 
wasting of muscles and no alteration of the electrical 
excitability ; the deep reflexes are usually exaggerated, but 
not modified otherwise. A fine rhythmical vibratile tremor 
of the fingers in the outstretched hand is nearly always 
present (9-10 per sec), like that met with in Grave's 
disease ; in fact, about 10 per cent, of cases of shell-shock 
neurasthenia exhibit mild signs of this endocrine affection. 
The tongue or lips may show tremor, and cause, or be 
associated with, some speech embarrassment. A vibratile 
tremor of the orbicularis oculi is very frequently present. 

Vertigo. — Dizziness, due to exhaustion of the cortical 
centres, is a constant and troublesome symptom. The 
patient usually complains of a feeling at times of instability 
when he assumes an erect attitude ; or it affects him often 
when he is crossing a thoroughfare. Less often, this 
feeling of giddiness is more or less continuous ; it may be 
associated with tinnitus {vide p. 186). 

Visual and Auditory Sensory Disturbances {vide 
pp. 185-87). 



192 WAR NEUROSES AND SHELL SHOCK 

Visceral- Vascular Symptoms. — Among the most im- 
portant symptoms of neurasthenia are those related to 
the viscero-vascular functions; for they may simulate 
closely many serious organic diseases. Of these the most 
important and most common 'are the Cardio-Vascular 
symptoms. 

Cardio-Vascular. — Very numerous are the cases of 
neurasthenia with cardiac symptoms which are designated 
D.A.H. (disordered action of the heart), and not a few 
V.D.H. (valvular disease of the heart). 

The term " irritable heart " is also used, especially 
when symptoms arise after muscular exertion. Functional 
disorders of the heart occurring in the subjects of neuras- 
thenia are very common in recruits and conscripts; it is 
therefore not to be wondered at that a number of soldiers 
and officers returned from the front suffering with neuras- 
thenia complain of palpitation, precordial pain and 
anxiety. Examination shows that there is rapid action 
of the heart increased upon slight exertion, and particularly 
by emotional disturbance or apprehension; there may be 
some evidence of dilatation, the cardiac dulness extending 
to the nipple line ; the apex beat may be diffused over an 
area the size of a crown piece and a soft systolic murmur 
may be heard at the apex which is not conducted into the 
axilla. Although the heart-beat is much more frequent 
than normal, the pressure is not appreciably raised and is 
sometimes lower than normal.^ 

^ A series of observations upon blood pressure in cases of Shell Shock 
and War Neurosis under my care have led to conflicting results. The 
earlier series made by Dr. Edith Green showed a greater number of CEises 
with a low blood pressure, while later observations made by Lieut. 
Huddleston, A.M.S., showed a preponderance of cases with a high blood 
pressure or pressure above normal. As I have no reason to doubt the 
accuracy of the methods employed I am of opinion that the type of 
cases was not proportionally the same in the two series. This explana- 
tion is all the more probable since Dr. P. Bousfield (" On the Relation of 
Blood Pressure to the Psychoneuroses," The Practitioner, November 1918) 
concludes from a series of observations that in a pure neurasthenia, unless 
complicated by organic disease, the blood pressure is usually subnormal. 
In a hysteria it is generally normal, in an anxiety neurosis it is more 
often than not considerably above normaL 



CARDIAC NEURASTHENIA 193 

The pulse-rate is usually increased, and it may be as 
rapid as 150; sometimes it is slow and arythmic; and 
cases of slow pulse and feeble heart action, according to 
Lewis, are more likely to suffer with an attack of syncope 
when undergoing training exercises than cases of tachy- 
cardia. 

Lewis thus describes these attacks : — 

" The syncopal attack may be preceded by a short 
interval of giddiness, by a severe weakness or unsteadiness. 
Consciousness is lost and the fall is sudden, but rarely 
heavy. Pallor and sweating are present. Involuntary 
movements are slight, and usually confined to the face 
and arms ; a general rigidity may be developed, the tongue 
is not bitten, neither is the urine passed. Nausea or 
vomiting may be present. The attack lasts for a few 
minutes and is followed by lassitude and headache. A 
history of earlier attacks is common ; these are associated 
usually with emotion, e. g. at sight of blood, also with long 
standing at attention, or the cessation of sudden effort ; they 
do not occur in recumbency." This description of Lewis 
is quoted in full, for unless it were known that such attacks 
may occur and that nevertheless a man suffering with 
them is able, according to Lewis, to return to drill after 
forty-eight hours, it might be thought that the patient was 
suffering with epilepsy, or, if they occurred in a man of 
over forty, that it was Stokes-Adams' disease. 

In some cases of cardiac neurasthenia the patients may 
suffer with attacks of pseudo-angina, the symptoms being 
a feeling of suffocation, anxiety and precordial pain 
radiating down the left arm. Enfeeblement of the heart's 
action with coldness of the hands and feet may also occur, 
or the pulse may become slow and arythmic. 

These cardio-vascular symptoms may be associated 
with respiratory difficulties simulating an asthmatic 
attack. Emotional disturbances are often accompanied 
by paroxysms of rapid breathing. Again, a man who has 



194 WAR NEUROSES AND SHELL SHOCK 

suffered with gas poisoning may have a reminiscence of 
the difficulty of breathing resulting in paroxysmal dyspnoea. 
Emotionalism may even show itself in the control of breath 
in speech. 

The vaso-motor disturbances of neurasthenia are either 




Fio. 54. — Median nerve paralysis. The insensitive area shows an acro- 
cyanosis which contrasts with the intact sensory area of ulnar 
distribution. 

due to arterial spasm, manifested by coldness (hypothermia) 
and blueness of the extremities (acro-cyanosis, vide Figs. 
54, 55) ; or to vaso-dilation, causing a feeling of rushing 
of blood to the head, flushing and blushing and a fear of 
the same erythrophobia. Sometimes a factitious urticaria 
occurs. 



GASTRO-INTESTINAL NEURASTHENIA 195 

Secretory. — Hyperidrosis may be general or local, and 
especially common is a condition of sweating palms of the 
hands. 

Gastro-Intestinal. — Symptoms of gastro-intestinal 
disorders are not at all uncommon. A very frequent 
condition is gastro-intestinal muscular atony, causing 
digestive disturbances and constipation; the patient com- 
plains of pains at the epigastrium relieved by food, but the 
digestion is slow and laborious, often accompanied by 
hyperacidity and pyrosis ; " hunger pains " are not in- 
frequent in these cases. Owing to the muscular atony, 
dilatation of the stomach and secondary fermentation 
arises. Sometimes acute crises of pain accompanied by 
vomiting may simulate the crises of tabes. 




Fio. 55. — Acro-cyanosis of neurasthenia. 

In severe cases anorexia, vomiting, diarrhoea, pallor, 
depression and even cachexia may supervene, causing 
gastric ulcer, duodenal ulcer, or even malignant disease 
to be suspected. When the vomiting is persistent and 
accompanied by severe headache, cerebral tumour or 
abscess may be considered as possible. A bismuth meal 
followed by X-ray examination will help to exclude the 
former; the absence of optic neuritis will serve in the 
differential diagnosis from the latter. 

The intestinal symptoms are irregularity of the bowels, 
obstinate constipation or diarrhoea, and sometimes a 
mucous colitis with passage of casts. These intestinal 



196 WAR NEUROSES AND SHELL SHOCK 

symptoms of neurasthenia may occur in a patient who 
has previously suffered with dysentery, and this makes 
the diagnosis more difficult. Again, a neurasthenic who. 
has suffered with appendicitis and who has had the appendix 
removed is liable to suffer with reminiscent intestinal 
symptoms. 

Genito-Urinary Symptoms. — Sexual neurasthenia is 
not so common in soldiers as in civilians. Still, a history 
of masturbation may be elicited causing an irritable 
weakness which may be associated with various disorders 
of the genital organs, e. g. the patient may complain of 
erection and nocturnal emissions, spontaneous emissions 
without erection, erections without emissions, incomplete 
coitus owing to ejaculation almost immediately, or to 
ejaculation without erection. Coitus in the neurasthenic 
is generally followed by lassitude and fatigue, or, as fre- 
quently happens in the neurasthenic soldier, there is a 
loss of sexual desire. There may be frequent desire to 
micturate; the urine is pale, of low specific gravity, 
containing a diminished quantity of urea, excess of phos- 
phates and often a deposit of oxalate crystals. Nocturnal 
enuresis occasionally occurs. 

The Mental State. — The patient is easily tired by any 
mental effort; he is unable to concentrate his attention. 
The intellectual faculties are not seriously affected, although 
the patient may complain of failing memory, especially of 
recent events. If there is any lack of comprehension, it 
is through lack of power of attention. The patient is 
often self-centred and introspective, but there is no per- 
version or any loss of the mental faculties. His reasoning 
and judgment may, however, be capricious and uncertain ; 
indeed, loss of will-power and irresolution in acting, owing 
to the fear of doing the wrong thing, makes the neuras- 
thenic officer fearful of responsibility and incapable of 
carrying on. The desire to " carry on " and not be con- 
sidered a shirker and the feeling of inability to do so is a 



DIAGNOSIS OF NEURASTHENIA 197 

constant source of anxiety causing insomnia and further 
neural exhaustion, from which the sufferer may obtain no 
rehef when he is sent home — for too often the mental 
conflict continues. 

Hypochondriasis and various morbid fears indicative 
of an obsessional psychasthenia are not uncommon, 
vide p. 205. It is of great importance to gain the full con- 
fidence of the patient by making a thorough examination 
in these cases of visceral neurosis the better to be able to 
assure them that their organs are not diseased and that 
the symptoms they are suffering from, and which alarm 
them, are due to nervous exhaustion and apprehension. 

Diagnosis. — A careful physical examination in order to 
exclude those organic diseases which are accompanied by 
the same or similar subjective symptoms will generally 
permit a correct diagnosis to be made. It is necessary to 
call attention to the fact that a neurasthenic may suffer 
from organic disease, although as a rule organic disease in 
soldiers is not to be expected, as they would not have been 
admitted into the army in such case. 

It must be remembered, however, that a number of 
organic diseases may come on after admission to the 
army, and one of the most frequent is phthisis ; and in the 
early stages of this disease subjective symptoms suggesting 
neurasthenia may occur, viz. palpitation, feeling of weak- 
ness, irritability, tiredness and a tendency to perspire 
unduly. Again, organic disease of the heart and arterio- 
sclerosis have to be excluded in neurasthenia with cardio- 
vascular symptoms. 

The diseases of the nervous system which may be 
mistaken for neurasthenia, are : (1) Paralytic dementia, 
especially in the early stages, with depression. (2) Tumour 
cerebri. (3) Tabes in the preataxic stage. (4) Cerebral 
syphilis. (5) Cerebro- spinal syphilis. (6) Cerebral abscess 
or encephalitis. (7) Disseminated sclerosis. (8) Various 
forms of toxic neuritis. (9) Chronic alcoholism. (10) 



198 WAR NEUROSES AND SHELL SHOCK 

Fractures and head injuries with or without associated 
neurasthenic symptoms. 

It is unnecessary to refer at length to the objective 
signs of these diseases, one or more of which are invariably 
present and serve as a means of differential diagnosis from 
a purely functional affection of the nervous system. Among 
the more important are pupil phenomena, changes in the 
fundus oculi, modifications of the superficial and deep 
reflexes ; and the presence of any one of these will suffice 
to indicate that there is an organic disease. Examination 
of the blood and cerebro-spinal fluid should be made in 
doubtful cases; and in cases of concussion or shell shock 
examination of the head and spine by X-ray for injury, or 
depressed fracture, should be made when organic signs are 
observed, or the history points to the possibility of injury 
even when there is no visible external evidence of it. I 
have seen cases diagnosed neurasthenia, in which an X-ray 
examination has demonstrated fracture; especially is this 
likely to occur in the frontal region, owing to the fact 
that the frontal lobes may be injured without giving rise 
to well-defined cerebral symptoms. It must always be 
remembered, however, that trauma may be associated 
with neurasthenia and, if not the sole causative factor, is 
an important contributary cause ; especially is this the 
case in neurasthenia following shell shock, for although 
there may be neither visible external evidence of injury 
to the head or spine, nor any gross nervous signs of organic 
disease, such as paralysis or irritation phenomena, never- 
theless, the higher functions of the brain may have been 
profoundly affected. A further proof that commotio 
cerebri has produced an effect upon the higher cerebral 
centres is afforded by the fact that alcohol has a more 
toxic effect. 

The subjects of concussion or shell shock are in an 
emotive state, and just as in civil life we know that 
legal intervention for the payment of claims under the 



COURSE AND PROGRESS 199 

Employers' Liability Act have led to deserving cases being 
subjected to prolonged worry, anxiety, sleeplessness and 
aggravation of the neurasthenic symptoms, so also cases 
of intensification of the symptoms are met with in soldiers 
and officers when their claims are hung up on account of 
the conflicting findings of Medical Boards. 



Course and Progress of the Psycho-neuroses 

The hysterical symptoms, mutism, aphonia, stammering, 
the spasms, tics, choreiform movements and the various 
forms of contractures and paralysis previously related, 
are often associated with symptoms of neurasthenia. The 
hysterical manifestations can be removed by contra- 
suggestion {vide p. 272-4) at once, but the neurasthenic 
symptoms persist for months; and it may be safely said 
that few cases of neurasthenia following shell shock or 
prolonged stress of war are fit for active service for at least 
six months, and many not for twelve months. 

The question arises whether patients suffering with 
severe symptoms, who after two months' hospital treat- 
ment are still haunted by terrifying dreams, would not do 
much better if they were permitted to return to civil life 
for a period of not less than six months, when they should 
be called up again. Many of these patients become 
hospitalised, and continual contact with others suffering 
with anxiety-neurosis does not conduce to an atmosphere 
of cure, which is one of the essentials in the treatment of 
psycho-neuroses. The atmosphere of cure, however, largely 
depends upon the administration, and nothing is more 
beneficial in the successful treatment of these functional 
nervous cases than the object-lesson of cure in long-standing 
cases of mutism, deafness, blindness, and of various 
paralyses, that for months had resisted treatment. As 
Charcot truly said, " C'est la foi qui sauve ou qui guerit," 
and although faith has not the same influence in the cure 



200 WAR NEUROSES AND SHELL SHOCK 

of neurasthenia as it has in hysteria, nevertheless it is 
only by faith in the treatment that the mind will find 
relief, and that the anxiety, which perpetually keeps up 
the exhaustion of the neural energy, will be allayed. It 
is only by faith in the doctor's examination and the assur- 
ance given to the patient that there is no organic disease 
and that he will get perfectly well, that the mind can be 
led away from dwelling upon and thereby increasing a 
disordered visceral function. The vicious circle between 
the anxious mind and the upset organ is broken by the 
faith which thrusts the idea out of consciousness and 
permits the organ to resume its normal unnoticed automatic 
action. 



The Psychoses of War 

Contrary to popular belief, there are no new clinical 
types of mental disease in soldiers. There are no " war 
psychoses." The clinical pictures, symptomatology and 
prognosis of the psychoses are the same in soldiers as those 
met with in civilians, the only modification being the 
coloration of the hallucinations, the illusions and the 
delusions by war experiences. 

In the majority of the cases of psychosis the war has 
only revealed, excited, or accelerated, and not caused the 
disease. Under the normal conditions of civil life the 
potentially insane individual may not be sufficiently anti- 
social to need restraint, but with the stress of war, and the 
necessity of conforming to military discipline and duty, 
his mental instability not only becomes apparent, but is 
a source of danger to himself and others; consequently 
evacuation as a rule is followed by discharge from the 
army. 

Still, there must be a considerable number of soldiers 
evacuated from the front suffering with only transitory 
mental symptoms, for 20 per cent, of the cases admitted 



THE PSYCHOSES OF WAR 



201 



to D. Block, Netley, labelled " Mental " are sent on to 
neurological hospitals. A number of cases have been 
admitted under my care with the diagnosis of " mental " 
and upon arrival these had already recovered from any 
signs of mental disease and have been treated in the 
general wards. 



The Psychoses 

In a conscript army there are all grades of mental 
stability, from the absolutely sound mind, in the sound 
body, to the unsound mind. No combination of extrinsic 
factors can in most of the former produce a mental in- 
stability. Head injury, emotional and physical shock, 
prolonged stress of war, and fever are insufficient ; whereas 
in the unsound mind any one factor may suffice to reveal, 
to excite or accelerate a mental disorder (psychosis). 
Between the two ends of the scale are all grades of mental 
stability. 

Dupre gives the following useful classification of the 
subjective signs and objective symptoms of the two 
primitive states, nervous exhaustion and emotivity. 

Headache. Racjiialgia, malaise. Ver- 
tigo. Sensorial hyperasthesia. Ac- 
commodative asthenopia. 
Slowing and enfeeblement of intellectual 
Subjective I operations. Easily fatigued by men- 
symptoms. \^ tal or bodily efforts. Amyosthenia. 
Painful feeling of fatigue, of power- 
PsYCHO- lessness, of weariness. Alternate 

NEURASTHENIA periods of excitement and depres- 

(constitutional ) sion; disorders of temper and 

or acquired). V character. 

Insomnia. 

Digestive troubles with emaciation, 

denutrition. 
Tachycardia, hypotension, tendency to 

hypothermia. 
Fatigability (reaction times increased 

— -disorders of gait and station). 



Objective 
signs. 



202 WAR NEUROSES AND SHELL SHOCK 



Psycho-neurosis 

Emotive 

(constitutional 

or acquired). 



Subjective 
symptoms. 



Objective 
signs. 



Impressionability by effective hyper- 
reflectivity in the sense of excitation 
or inhibition. 

Terror, timidity ; continued and par- 
oxysmal anxiety, diffuse or localised. 
Obsessions, phobias, doubts and 
scruples, etc. 

Irascibility. 

Various disorders of psycho-sexualily. 

Sensory-motor erethisms exhibited by 
hyper-reflectivity of tendons, cuta- 
neous and sensorial, of non-organic 
character. 

Motor disequilibrium : tremors, visceral 
spasms, palpitations ; tachycardia, 
often permanent and variable. 

Vaso-motor disequilibrium : blushing, 
pallors, dermatographism. 

Glandular disequilibrium : crises, epi- 
sodic-spontaneous or provoked in- 
versions of secretions, urinary, sweat- 
ing, intestinal, salivary, lachrymal. 

Pharmacodynamic disequilibrium. 



" These two states can, by their exaggeration, episodic 
or continuous, terminate in deUrious psychopathic syn- 
dromes ; psycho-neurasthenia to different forms of mental 
confusion ; morbid emotivity to anxiety psychopathies. 
The frequent association of the two primitive states 
(neurasthenia and emotivity) is often then reflected in 
the combination of secondary syndromes; confusion with 
anxiety. Morbid emotivity assumes sometimes a special 
form characterised by the electivity of anxiety-reactions 
towards events or situations of the war, particularly ex- 
plosions, risks of assaults, of bombardments. The emotive 
state is manifested in soldiers in the form of irresistible 
fear of dangers of war, associated with crises of anxiety 
and terror at the front, impulsions and frequently desertion 
from post of duty. 

" These acute or subacute states, very varied in their 
forms, their associations, their evolution, their duration, 
can at the end of some months or of a year or two be 
cured, or after on incomplete amelioration become chronic 



THE PSYCHOSES OF WAR 



203 



and remain stationary, or eventually be aggravated into a 
progressive involution. 



^(1) Traumatic or acute infections of 
exogenous origin, of direct and military 
etiology, wounds of the head, commo- 

■ tions, fevers contracted in the Service. 

Dementias.! (2) Chronic organic, of endogenous origin, 

of indirect and extra military etiology, 

general paralysis, arterio - sclerosis, 

cerebral syphilis, alcohol. 



B. Chronic 

Psychopathies 

(incurable, 

stationary or 

progressive). 



Chronic 
Psychoses. 



[(1) Post-confusional Psychoses of depres- 
sive form, and demential deliriant. 

(2) Intermittent Psychoses. Maniacal or 
Melancholic attack, first attack, or 
preceded by similar attacks prior to 
the war. 

(3) Chronic Psychoses of a first insane 
type. 



"Among the chronic states (1) the Dementias, (1) the 
Psychoses are the direct consequences of the war; the 
others, Dementias (2) and the Chronic Psychoses (2 and 3), 
are either totally unconnected with military service or 
indirectly provoked by the war, which play in their deter- 
mination an etiological role either revelator, or aggravator, 
or accelerator."^ — Dupre. 



Exhaustion Psychosis 

The psychoses which are especially attributed to war 
are the various types of confusional insanity, or, as it is 
frequently termed, exhaustion psychosis. Regarding this 
psychosis we have already seen that shock, whether 
emotional, commotional or, as more often happens, a 
combination of the two, is responsible for a state of mental 
confusion which, as in some cases of concussion, may 
persist for a considerable time. But a careful inquiry 
into the family history and upbringing of these cases will 
usually show a predisposing constitutional condition. 

Hallucinatory mental confusion or, as the French term it, 
" oniric delirium," is characterised by mental enfeeblement 



204 WAR NEUROSES AND SHELL SHOCK 

and confusion; also there is disorientation in time and 
space, but there is besides an active dehrium, coloured 
by the experiences of the war. It is not only ideational 
delirium, but it is a delirium of action. A prey to day- 
dreams, the subject loses contact with reality, and patients 
thus affected may show a complete disregard of danger 
by placing themselves in exposed and dangerous positions 
without exhibiting any fear. As these patients forget all 
about their actions these cases are of importance from a 
medico-legal point of view. 

As regards exhaustion being a cause of this psychosis 
there is a considerable difference of opinion ; undoubtedly 
exhaustion psychosis is a comforting term to use when we 
do not know what the mental condition exactly is, nor what 
the outlook is. The patient may have had a fever such as 
typhoid, malaria, influenza or pneumonia, etc., which in 
some instances has been preceded or followed by pro- 
longed stress of war. A mental disorder, characterised 
by confusion, follows, and it is assumed that it is due to 
an exhaustion process affecting the brain, but the facts 
about to be related rather indicate that a constitutional 
predisposing cause is at the root of most cases diagnosed 
as exhaustion psychosis. " For amongst 10,000 Serbs 
who were taken prisoners of war after suffering the most 
severe exhaustion, hunger, and loss of sleep, and after being 
subjected to all manner of infectious illnesses, leading to 
cardiac 'weakness with oedema, gross wasting, great loss 
of strength and a high mortality from tuberculosis and 
other infectious diseases, only five cases of psychosis 
developed, a number not higher than would have been 
expected in peace times amongst a similar number of 
civilians." From this it may be deduced, says Bonhceffcr, 
that the acute exhausting influences of malnutrition, lack 
of sleep, and excessive exhaustion do not of themselves 
lead to the development of psychoses ; and he agrees with 
Aschaffenburg that exhaustion and overwork must be 



THE PSYCHOSES OF WAR 205 

relegated to the background when considering the psycho- 
pathogenetic causes of mental diseases. Microbial toxins 
of infectious diseases are usually held to be one of the 
principal causes of exhaustion psychoses. When a man 
has been exposed to shell fire and he has acquired an 
infectious disease, the onset of an exhaustion psychosis 
is apt to be attributed to shell shock. 

Then with regard to emotional causes Bonhoeffer points 
out that Bresler in 1914 showed that the so-called mobilisa- 
tion psychoses were all either the reactions in patients 
who had formerly suffered with mental disease or else 
other forms of psychopathic reactions. 

In the women who fled from Galicia and East Prussia 
and in the civil population of the invaded territories of 
Northern France, no great increase of mental disease has 
occurred. 

Balz has shown that fright leads to an emotional 
paralysis and a dissociation of consciousness which in 
general lasts for a short time only, but which in certain 
pathogenic states may persist for a considerable time as 
hystero-neurotic manifestations. 

Dementia Prsecox 

Dementia prsecox must necessarily occur in a number 
of adolescents after joining the army. About 14 per cent, 
of mental cases in soldiers suffer with this disease. A 
careful inquiry into the history of these cases frequently 
shows that prior to military service there were indications 
in their conduct and behaviour pointing to a mental 
instability or derangement, or possibly there is a history 
of what is termed a nervous breakdown. On joining the 
army and before they have seen active service the disease 
often reveals itself by petty delinquencies such as late for 
parade, dirty gun, absence without leave. At first they 
are punished, then a medical inquiry is instituted and the 



206 WAR NEUROSES AND SHELL SHOCK 

disease is suspected or diagnosed. There appears to be 
no special modification of symptoms on account of military 
service. The same three types of kalatonic, hebophrenic 
and paranoidal are met with. 

Most of the cases of dementia praecox are revealed during 
military training. Severe commotional cases in which 
there is emotional indifference and stupor with complete 
anterograde and retrograde amnesia might be mistaken 
for dementia praecox in cases where a history cannot be 
obtained. 



Psychasthenia 

Psychasthenia is a term applied to anxiety-neurosis 
with morbid obsessions and phobias associated with signs 
and symptoms of nervous exhaustion. There is nearly 
always a history of an inborn psychopathic tendency in 
patients suffering with psychasthenia. Not infrequently 
there is a history of head injury or commotion. 

The paroxysms of anxiety may be associated with 
tachycardia, hypotension of the pulse, and vaso-motor 
reactions, arising without any special cause. The power of 
reasoning and judgment may in all respects, except concern- 
ing the morbid obsession or phobia, be normal. However, 
by reason of the exhaustion and the inborn psychopathy 
there may be a failure of logical sequence of thought and 
conversation ; this is not due so much to failure of com- 
prehension as to inability to concentrate attention. This 
condition is so pronounced at certain moments in severe 
cases that the patient at times appears to suffer from a 
mental eclipse. Although there may be times when the 
patient presents an abeyance of symptoms, nevertheless 
the disease, having its roots in an inborn tendency, 
these periods of calm or comparative calm are liable at 
any time to give place to active periods, characterised by 
a return of the obsession with its accompanying distressing 



THE PSYCHOSES OF WAR 207 

anxiety. The symptoms are not relieved by drugs. In 
the less unfavourable cases a treatment combining both 
the principles of the rest cure and psychotherapy may 
bring about a sufficient adaptation to enable the patient 
to be of some military use. As a general rule cases of 
obsessional psychasthenia are of little military value, and 
should be discharged from the service. Of the various 
phobias met with, claustrophobia (fear of closed spaces), 
agorophobia (fear of crowded places), and syphilophobia 
are, according to my experience, by far the commonest. 
Associated with these morbid fears there may be a certain 
degree of mental confusion. In severe cases, which, how- 
ever, are rare, the mental confusion • may be associated 
with hallucinations. 



Feeblemindedness 

Quite a number of soldiers have been conscripted who 
are feebleminded; they are mental defectives, and upon 
inquiry they will be found to have only reached a very 
low standard in the school, subsequently they were out 
of work as often as employed, and they were of low wage- 
earning capacity. Frequently these men are not only 
mentally but physically inferior, and such should never 
have been recruited, for they will not repay military 
training. Not a few of these mental defectives are also 
congenital epileptic imbeciles. 

xlbout 18-20 per cent, of the admissions to military 
mental hospitals are mentally defective. A small propor- 
tion of these are high-grade imbeciles of the criminal type ; 
the remainder are mentally and often physically so inferior 
that although they had no criminal propensities, yet 
experience has shown that for the most part they are quite 
useless for active service : " Sometimes they had proved 
dangerous to their comrades, and were permitted to load 
their rifles only when an attack was made." 



208 WAR NEUROSES AND SHELL SHOCK 

Epilepsy 

The question of epilepsy arising from stress of war and 
shell shock is of great importance, and in a discussion 
which took place in January 1916 at the Royal Society of 
Medicine upon " Shell Shock without Visible Injury," 
Dr. James Collier stated : "I do not think psychopathic 
and neuropathic antecedents are of importance as deter- 
minants of functional manifestations. What seems more 
important are the proximity of the explosion and the 
violence of the sensory effect, provided consciousness be 
retained." He then went on to say : " Major Mott has 
referred to epilepsy occurring only in those who had 
previously had fits or in whom there is a family history 
of the disease." What I did say was : " The history 
showed that cases which were said to have developed true 
epilepsy as a result of shell shock, were either nearly always 
individuals who had previously suffered with true epilepsy 
or an anomalous form of it, or that they were potential 
epileptics prior to the shock; this might be assumed from 
the fact that they had suffered with slight faints or auto- 
matisms, or that there was a history of epilepsy or insanity 
in the family." In support of this statement I carefully 
summarised the pre-war histories of all the cases of epilepsy 
under my care who had been returned from the front for 
six months. I was enabled, from the very careful notes 
taken for me by Dr. Cicely May Peake, who for six months 
devoted her whole time to investigating these functional 
cases for the Medical Research Committee, to show that 
my statement was based upon facts {vide p. 108). Subse- 
quent investigations by myself and others have convinced 
me that true idiopathic epilepsy is constitutional and can 
seldom be attributed to commotion. Dr. Salmon states 
that : " Seven per cent, of cases received at Dykebar War 
Hospital were suffering from epilepsy. With one exception 
all had the disease before enlistment." This question is 



DIAGNOSIS OF EPILEPSY 209 

of great importance in deciding whether a pension should 
be granted. Now epileptics are not admitted to the army, 
if it be known, and recruits are required to state that they 
have not suffered from epilepsy. Many do not know, 
but some wilfully conceal the fact that they had previously 
had fits, or they may think that they have been cured. 
Again, a man may know that if he can claim that he is an 
epileptic his services will be no longer required, and he 
can state that the shell shock was the cause, and claim a 
pension for being incapacitated by active service. A few 
epileptics make good soldiers, but in the majority of 
instances they are unfit for active service, not only because 
at a critical moment they might have a fit or psychic 
equivalent of a fit, but because many of them cannot 
submit to discipline. 



Differential Diagnosis of Idiopathic Epilepsy and 
Traumatic Epilepsy 

A number of cases are sent back from active service on 
account of " fits." The fits are not infrequently said to 
have come on in consequence of shell shock, gunshot 
wounds of head or contusions from various causes. A 
careful inquiry often reveals the fact that the man had 
suffered with fits before he joined the army. Fits which 
make their first appearance soon after, or in consequence 
of a head injury or commotion, are hysteric in origin. 
Undoubtedly Jacksonian epilepsy may arise as a result 
of penetrating wounds of the skull and depressed fractures 
near or over the motor area. Later encephalitis, cystic 
degeneration, or meningitis near the motor area may 
give rise to epileptiform seizures without paralysis. These 
Jacksonian fits proceed at first by a definite march and 
tend by continuance to extend to the whole of the body, 
' so that the clonic spasms spreading rapidly with loss of 
consciousness may cause a fit which resembles idiopathic 



210 WAR NEUROSES AND SHELL SHOCK 

epilepsy. The history of an injury to the skull, the 
evidence afforded by examination (aided by X-rays, if 
necessary) and a description of the onset and march of the 
fits when they first occurred, will suffice to differentiate 
idiopathic epilepsy occurring in a man who has suffered 
with a head injury. This is of importance when a pension 
or gratuity is considered. 

In Babinski's service at the Hopital de Buffon, amongst 
150 cases of cranio-cerebral traumatism there were 19 
cases of generalised epilepsy, whilst there were only 15 
of Jacksonian. According to Netter the generalised 
traumatic epileptic seizures resembled attacks of idio- 
pathic epilepsy, but showed the following peculiarities : 
greater frequency of an aura, the nature of which depended 
upon the seat of the lesion, and the predominance of th£ 
convulsions on the opposite side of the body to that of 
the trauma which may affect the frontal, temporal, parietal 
or occipital regions. 

Injury of the frontal lobe may be followed by no epilepti- 
form convulsive attacks, but I have seen several cases of 
automatic wandering without any other symptoms follow 
injury of the frontal lobe. 

Differential Diagnosis of Epilepsy and Hystero- 

Epilepsy 

Before epilepsy is diagnosed in a man who suffers with 
fits the army regulation requires that a fit should be 
witnessed by a medical officer. But he should do more 
than witness the fit, he should ascertain the premonitory 
symptoms and observe the after-effects upon the patient's 
conduct and general behaviour. Jellinck has pointed out 
that for 5-15 minutes after a fit the plantar reflex is 
extensor instead of flexor. 

When a diagnosis of epilepsy has been made the question 
arises. What should be done with the patient? Before 



DIAGNOSIS OF EPILEPSY 211 

man-power became a serious problem the patient was 
boarded out of the service, now we have to consider 
whether he cannot be utiHsed in one of the categories for 
home service. A few cases can be placed in Bl for garrison 
duty, a larger number can be utilised for labour and placed 
in B2 and a certain number in B3 for sedentary occupations. 
I prefer to board them out of the service if they can be 
utilised for work on the land as farm labourers, for that 
occupation is most suitable for them. 

A number of cases returned as epilepsy are really hystero- 
epilepsy; the patient loses consciousness and exhibits 
motor reactions which might easily be mistaken for those 
of true epilepsy, except that they are excentric rather than 
concentric. The patient rapidly recovers, instead of 
falling into a deep sleep as occurs in epilepsy. Bromides 
have little influence in preventing these psychogenic 
seizures. 

Lapses of memory of a psychogenic nature are liable 
to be confounded with attacks of masked epilepsy (fugues), 
in which the patient, instead of having a fit, behaves 
like an automaton. 

The military value of hystero-epileptics is extremely 
low ; they are only fit for home service, in one of the 
grades Bl, B2, or B3. In fact, similar treatment is 
required as in the case of epileptics. 

The epileptic is much more liable to become dangerous 
to himself and others than the hystero-epileptic. In 
illustration thereof, I will cite a case which came under 
my notice. An alien Jew, who had voluntarily enlisted 
early in the war, was discharged from the service on 
account of fits. He re-enlisted in another regiment. 
Later he was sent to the 4th London General Hospital 
to be examined and reported upon; as he had attempted 
to kill his CO. and the policeman who arrested him. He 
had, he stated, no recollection of the incident. Later 
he had a typical epileptic convulsive seizure ; I ascertained 



212 WAR NEUROSES AND SHELL SHOCK 

that his father had been for ten years in Cohiey Hatch 
Asylum suffering with a similar affection. 

Attacks of " petit mal " are frequently not recognised by 
the patient as of an epileptic nature, but considered to 
be simple faints; consequently a soldier suffering with 
" petit mal " may declare that he has never had fits. 
Under the stress of war or in consequence of an emotional 
or commotional shock he may have his first convulsive 
seizure; the psychopathic constitutional factor conse- 
quently may not then be evaluated, for he will assert that 
he had never had fits and that the conditions of war have 
been the cause of the onset. A careful inquiry should 
therefore always be made both as regards the previous 
history of the patient and his family history; and in a 
large number of cases it will then be found that there was 
a pre-war history of epilepsy or an inborn predisposition. 



Masked Epilepsy 

Larval epilepsy in the form of fugues and periodic 
attacks of mental instability causing the individual to 
commit acts for which he may subsequently have no 
recollection and for which he cannot be legally held 
responsible, are frequently the cause of court martials. 
In such cases a careful history should be taken and the 
friends interviewed, if possible, to corroborate the state- 
ments, or throw light upon the case. Several cases have 
come under my notice in which a soldier was charged with 
either desertion or absence without leave, and information 
obtained from the nearest relations has proved conclusively 
that the man was an epileptic. It must, however, be born 
in mind that soldiers will plead on the grounds of epilepsy 
that " they were not conscious of the quality of their acts " 
when charged with desertion. 

Soldiers of the old army were apparently sometimes 
aware of automatic wandering being a form of masked 



MASKED EPILEPSY 213 

epilepsy, and to escape punishment pleaded they had no 
recollection of what happened during a period of absence 
without leave. This form of malingering to escape punish- 
ment is not always easy to detect, but motives for this con- 
duct and careful inquiry into the family and personal history 
will generally enable a correct judgment to be formed. 

Some authorities find hypnotism a useful aid in the 
differential diagnosis between hysteria and epilepsy. The 
hysterical patient at the word of command reproduces the 
complete attack in all its details, whereas the epileptic, 
though he may carry out all the commands, shows no 
reaction. 

The following case of hysteria illustrates this point. 
A young soldier who had been sent from the front was 
observed to have a curious mode of progression. He 
would take a few steps and then make a double shuffle 
forward of his feet, without hardly raising them. I placed 
him on a couch and sent him to sleep; he fell off the 
couch towards the left, turned over on his face and then 
commenced a rapid movement of both arms and legs, like 
running away. This same fit could always be reproduced. 
It had its commencement when a shell burst near him in 
a trench. 

Manic Depressive Insanity- 
Manic depressive insanity or periodic insanity is nearly 
always due to an inborn constitutional psychopathic 
tendency, and in the majority of cases attacks of depression 
with agitation and excitement have occurred prior to the 
war, if there has not been actually an attack of certifiable 
insanity. These cases nearly always give, on inquiry, 
some evidence by the family history of a psychopathic 
tendency. The delusions, illusions and hallucinations 
are nearly always coloured by war experiences. The 
attacks do not seem to be promoted by stress of war, in 
the majority of cases, any more than other forms of 



214 WAR NEUROSES AND SHELL SHOCK 

psychosis. No one with a definite history of an attack 
of manic-depressive insanity should be considered fit for 
miUtary service, as the tendency to recur is one of its chief 
features. About 20 per cent, of the admissions to the 
mihtary hospitals for mental diseases belong to this group. 

Paranoia — Acute and Chronic Delusional Insanity 

Paranoia — systcmatiscd delusional insanity — is not in- 
frequent, and is usually characterised by delusions of 
persecution and self-accusations, generally having some 
relation to war experiences, and often based upon hal- 
lucinations and illusions. In these cases of delusional 
insanity there is frequently a family history pointing to 
a psychopath c inheritance. Cases, however, are sent 
back from the front as mental, and said to be suffering 
with delusions of persecution which, when investigated by 
an expert, are found to be sane, and the most that can be 
said of them is that they have either exaggerated their 
troubles or have imagined they have been unfairly dealt 
with by superior officers or non-commissioned officers. In 
a few instances undoubtedly they have had real grievances 
and should not have been returned as " mental." 

Disposal of Mental Gases. 

In nearly all these forms of psychosis, as also of epilepsy, 
the question of pension and gratuity is a difficult one to 
decide. The Government, having accepted for military 
service men who afterwards develop a psychosis, has 
recognised responsibility for their care and treatment. 
No man suffering with a psychosis, who has served abroad, 
can be sent to a county or borough asylum until a reason- 
able period has elapsed, or it is deemed that the case is 
chronic or incurable. Certain cases of epileptic insanity 
and general paralysis with well-defined mental symptoms 
can be at once sent to a county asylum. Special hospitals 



ORGANIC BRAIN DISEASES 215 

for mental cases have been provided for men and officers, 
and quite a number of cases diagnosed as exhaustion 
psychosis or confusional insanity are discharged as cured, 
or as sufficiently recovered to be given over to the care 
of their friends. 



General Paralysis and other Organic Brain 
Diseases 

General paralysis is now recognised to be invariably due 
to syphilitic infection upon an average ten to fifteen years 
previously. As a general rule no signs of syphilis are 
recognisable on the body, and in a large number of cases 
the primary infection was not recognised and treatment 
was either absent, late in its application, or insufficient. 
Skin lesions are very rarely met with, so that, unless a 
Wassermann reaction of the blood be made, latent syphilis 
would not be suspected. But if all conscripts with a 
positive reaction of the blood were rejected, nearly 10 per 
cent, of ablebodied men would not be admitted to the 
army. I examined for Sir John CoUie 500 specimens of 
blood taken from men in apparent health, who applied 
for employment in the service of the L.C.C., and nearly 
10 per cent, gave a positive reaction. Having, therefore, 
conscripted men with latent syphihs of the central nervous 
system, two important questions arise. (1) Does the stress 
of war convert latent syphilis of the nervous system into 
an active disease by promoting the growth of the spiro- 
chsetes? (2) What should make the medical officer suspect 
this latent syphiHs of the nervous system, when examining 
a recruit or soldier? Examination of the pupils in a 
considerable number of cases serves to reveal the disease 
before any symptoms or other signs have developed. In 
fact, the presence of the Argyl-Robertson pupil phenomenon 
shows that a man is a candidate for tabes or general 
paralysis, even when no other symptoms can be detected. 



216 WAR NEUROSES AND SHELL SHOCK 

Next in importance to the Argyl-Robertson phenomenon is 
the irregular pupil, which is more often met with than the 
fixed pupil in general paralysis in the early stages. Again, 
as in the other cases, unequal pupils are very significant 
and should always lead to further investigation of the 
nervous system by examination of the cerebro-spinal fluid 
for lymphocytosis, globulin and Wassermann reactions. 
I have seen cases of tabes and general paralysis which 
have been recruited, in which in all probability the pupil 
phenomena had been overlooked. Quite a number of 
cases in the predemential, preparetic and preataxic stage 
of these two syphilitic diseases have come under my 
notice. Some have been sent back for shell shock, others 
as neurasthenia, and a few have been diagnosed as general 
paralysis, or a query diagnosis has been made, for clinico- 
pathological investigation to decide for or against general 
paresis. • 

Some of these cases have had an attack of mania, 
recovered, and the disease had been apparently arrested 
by treatment; and in these the pupil phenomena were 
the sole objective signs of the existence of the disease. 
Examination of the cerebro-spinal fluid showed that the 
organism was still in the nervous system. 

It has been found that the average age of the soldier 
who suffers with general paralysis is less than that of the 
civilian so affected. It may be assumed that shock from 
commotion or emotion may produce a vascular disturbance 
in the brain, causing a temporary cortical anaemia, thus 
exciting the onset of general paralysis by converting a 
latent into an active disease. 

Although syphilis, therefore, is the essential cause of 
both tabes and general paralysis, nevertheless, a man with 
latent syphilis who has been conscripted should be entitled, 
and his wife also, to some compensation in the form of 
pension or gratuity, if either of these diseases develop 
subsequent to his admission to the army. 



DIAGNOSIS OF MALINGERING 217 

Of organic brain diseases, syphilis is the most frequently 
met with, as it causes various paralyses, speech defects 
and other motor, sensory, and mental disorders, as well as 
disabilities of the most varied kind, according to the 
nature of the lesions and their localisation in the nervous 
system. Tumours, tubercular meningitis and cerebro- 
spinal meningitis may occasionally be admitted with a 
diagnosis of shell shock. But persistent and increasing 
signs of intracranial pressure in the first-named and 
the result of the examination of the cerebro-spinal fluid 
in the two latter will enable a diagnosis to be made. 
Cerebral abscess from old frontal sinus or ear disease that 
has been latent for years may become active or rupture 
into the ventricles, and if the soldier has been exposed to 
shell fire it may lead to a diagnosis of shell shock. A 
more frequent cause of cerebral abscess are penetrating 
gunshot wounds of the head. The abscess may not 
develop till many months have elapsed after the injury. 

The Diagnosis of Malingering 

In the diagnosis of malingering there are certain general 
guiding principles to be considered. The first and most 
obvious is the discovery of the mind's construction in the 
face, a matter of individual skill which is in a great measure 
intuitive and cannot be taught ; it is, as Maudsley says, 
" An act the principles of which it has not yet been possible 
to formulate ; but there can be no doubt of the extra- 
ordinary skill which some persons acquire, or the value 
of the information Avhich those who have the requisite 
acuteness and experience may obtain thereby." For, as 
Bacon said, " The lineaments of the body do dispose the 
disposition and inclination of the mind in general ; but 
the motions of the countenance and parts do not only so, 
but do further disclose the present humour and state of 
the mind or will." 

Again, Bacon says, "It is hard to find so great and 



218 WAR NEUROSES AND SHELL SHOCK 

masterly a dissembler or a countenance so well broke and 
commanded as to carry on an artful and counterfeit 
discourse without some way or other betraying it." 

It is in and around the eyes that we may discern most 
clearly deceit and cunning. The glance is furtive and the 
malingerer betrays uneasiness and suspicion when closely 
watched. 

The expert should remember that he is not the only 
person who is studying the facial expression. He should 
maintain an impassive mien, for his countenance is b(ing 
closely watched by a cunning and designing man ready 
to take to account any change of expression which would 
afford information. 

Behaviour when under Examination 

Some impostors exhibit an air of extreme simplicity, 
others assume a blunt manner and bluff, which they 
maintain even when they know they are found out. 

Others, again, are resentful to examination, and are 
surly or ill-tempered. " But the special pitfall of the 
malingerer is his tendency to overact his part." Conse- 
quently it is rare that the malingerer does not sooner or 
later give himself away by some inconsistency or contra- 
diction. Again, fraud may be manifest by some circum- 
stance or act. 

The illiterate man, on the one hand, through lack of 
knowledge resorts to cunning. He exercises his ingenuity 
in either withholding or concealing information. He refuses 
to give direct answers to questions even when they have 
no bearing upon his case. The clever, crafty man, on the 
other hand, has a plausible tale to tell, and protests loudly 
his honesty and desire to afford as much information as he 
can. He usually overdoes it and thereby excites suspicion, 
which leads to his being closely watched and found out. 

The simulation of insanity to avoid service or escape 
punishment for a crime is not an infrequent mode of 



DIAGNOSIS OF MALINGERING 219 

malingering. Before an opinion can be given it is usually 
necessary to take the man into the hospital for observation. 

The trump card which the malingerer plays is pain, a 
subjective symptom the existence of which it is difficult 
to deny, but the pain complained of he is incapable 
of localising, or he is only able to give vague answers 
respecting its situation. On one point he is very sure, 
and that is its severity, which has no remissions and 
is uninfluenced by treatment. But this is not in accord- 
ance with genuine pain caused by disease or injury.^ If 
there is any evident disease or injury, however simple or 
slight, he makes the most of it, and oversteps the limits 
of genuine disability from such a cause. Often he affects 
symptoms foreign to the disease he seeks to imitate. 

Ignorant of the causes that are capable of producing 
the disease he simulates, the malingerer favours such 
conditions as inoculation and vaccination, and this may 
lead to his undoing. 

Many injuries and diseases which are simulated should 
lead to definite organic changes and objective signs. Thus 
in alleged coxalgia there will in time be discoverable 
changes in the joint and muscular wasting. In sciatica 
there will likewise be muscular wasting and changes in 
the electrical reactions tested by the condenser. 

As malingering is a crime and its detection may be 
followed by severe punishment, it is very necessary to 
approach the case of a suspected malingerer without any 
bias and in a friendly manner, thereby gaining confidence 
and allaying suspicion. The observer should quietly and 
unconcernedly note the gait and station of the man as he 
comes into the room. Watch the manner he stands to 
attention and salutes. He may be left to undress for 
examination, and unseen he may be watched how he takes 
off his trousers and unlaces his boots ; for all these acts 

^ The seat of pain does not correspond to the anatomical distribution 
of a sensory nerve (vide Figs., Appendix), nor does it correspond to the 
referred pain of spinal segmental distribution (vide Table, p. 176). 



220 WAR NEUROSES AND SHELL SHOCK 

will give valuable information as to mobility of the joints 
and pain caused by movement. If he complains of a 
stiff knee, give him a low chair to sit down upon and 
observe if he bends it. If he should complain of feeling 
ill, take his temperature, pulse and respiration, and ascer- 
tain if he eats well and sleeps well. Also note his general 
attitude to his comrades and their attitude towards him. 
A man who swings the lead is generally known, and although 
his comrades will not give him away, they usually despise 
him and are glad when he is detected. 

Questions in cases of wounds and injuries cannot be too 
searching. Careful consideration of his answers will often 
enable a correct estimate to be made of the degree of 
disability which would be caused thereby and the probable 
duration of it. 

The Exclusion of Organic or Functional Disease 

It is necessary to exclude organic or functional disease. 
Attention should be directed in every case to the mobility 
of all the joints ; the evidence of any muscular wasting ; 
the reaction to Faradism ; ^ the pupillary reactions ; the 
ophthalmoscopic examination of the fundus oculi ; the 
condition of the superficial and deep reflexes ; the ability 
to stand with the eyes shut without swaying ; the existence 
of tremors of the outstretched fingers and of the eyelids, 
of the tongue and of the lips ; and where necessary an 
X-ray examination. 

Mistakes are made more often by not looking than not 
knowing, and a thorough neurological examination should 
always be made. So that the malingerer should not be 
able in defence to say, " Why, he never even examined me." 

Quite early in the war I was asked to report on a reservist 
who had been in bed some weeks professedly unable to 
stand or walk. He was suspected of malingering, and 

^ In testing the reaction Erb's motor points should bo the part of the 
muscle to which the different electrode is applied {vide Figs., Appendix). 



DIAGNOSIS OF MALINGERING 221 

was sent to the hospital for an expert opinion and report. 
I made a systematic neurological examination, and could 
find no evidence of organic or functional disease. He 
complained of pain in the spine. I therefore told him to 
indicate exactly the painful spot's on percussion. These I 
marked with a blue pencil. I then repeated the manoeuvre, 
and found he indicated quite different points as being 
painful. I observed that his ears, as I sat behind him, 
were getting redder and redder. I stopped suddenly and 
said, " My man, I have given half an hour to your case, 
and I cannot find it conforms to any known disease. Get 
up at once." Which he did, and was promptly returned 
to his depot. 

The element of surprise is sometimes useful where a 
malingerer overacts his part. A case of pseudo-coxalgia 
was sent to me for an expert opinion. He had been many 
months in hospital; he walked lame and complained of 
pain on passive movements of the hip. There was some- 
thing in his facial expression and general behaviour which 
suggested that he was a malingerer or gross exaggerator. 
He was resentful to examination, and his general behaviour 
was unsatisfactory. I asked him whether he felt the 
vibration of a large tuning-fork placed on the shin-bone 
of the disabled leg. His reply was, " No, sir." I said, 
"You are a liar. Now, do you feel it?" He replied, 
" Yes, sir," and asked to be returned to his unit. 

A Hebrew consulted me for neurasthenia with a view to 
obtaining exemption. He said he suffered with congenital 
deafness. I whispered in the left ear (which he said was 
the worst), " Put out your tongue," which he promptly did. 

The malingerer can often be found out by suggestion 
of a disability. Thus a recruit was sent to me for a report 
as to fitness. He complained of a number of vague sub- 
jective symptoms difficult of proof or disj^roof. I said, 
" What about the sight ? " "I can't see properly with 
my right eye." I replied, " That is a definite disability, 



222 WAR NEUROSES AND SHELL SHOCK 

but perhaps it can be remedied with a strong glass." He 
was given test type to read, and of course he was unable 
to read even the large type with that eye. I then put on 
a + '25, and he was able to read all the type, and equally 
as well with a — '25. A report was sent in accordance with 
this finding. 



Alcohol and War Neuroses 

An inquiry regarding the influence of alcohol in the 
production of war neuroses and the value of the rum 
ration, which I undertook with the aid of Dr. Edith (ireen 
at the Maudsley Neurological Clearing Hospital, is of 
considerable interest. 

A system of cards of four colours was employed : 
(1) White for Total Abstainers; (2) Blue for Occasional 
Moderate Drinkers ; (3) Pink for Daily Moderate Drinkers ; 
(4) Green for Heavy Drinkers. 

One hundred and forty-seven cards were collected from 
the Maudsley patients, and sixty-two cards collected from 
Ruskin Park patients ; the latter were patients who 
neither suffered from shell shock nor war neuroses. 

Subjoined is a summary of this investigation. 

147 Cases from Maudsley Neurological Clearing 
Hospital 
90 Patients claiming to be Abstainers, and of these : — 
45 did not take the ration ; 
39 did take the ration ; 23 of whom found it beneficial ; 

15 ,, did not find it beneficial ; 

1 ,, it made no effect. 
6 were not offered the ration. 

19 Patients claiming to be Occasional Moderate 
Drinkers, and of these : — 
6 did not take the ration. 
13 took the ration ; 6 of whom found it beneficial ; 

5 ,, did not find it beneficial : 
2 ,; state that it made no effect. 



ALCOHOL AND WAR NEUROSES 223 

31 Patients claiming to be Daily Moderate Drinkers, 
and of these : — 

2 did not take the ration ; 

29 took the ration ; 23 of whom found it beneficial ; 

4 ,, did not find it beneficial ; 
1 „ states that it made no effect ; 
1 ,, made no remark at all. 

7 Patients claiming to be Heavy Drinkers, and of these : — 
6 took the ration without comment ; 
1 did not take it, but gave no reason. 

62 Cases from Ruskin Park 

(These patients neither suffered from Shell Shock nor War 

Neuroses.) 

18 Patients claiming to be Abstainers, and of these : — 

8 never took the ration ; 
10 took the ration and found it beneficial. 

9 Patients claiming to be Occasional Moderate Drinkers, 
and of these : — 

3 did not take the ration ; 

6 took the ration and found it beneficial. 

34 Patients claiming to be Daily Moderate Drinkers, 
and of these :— 

3 did not get the opportunity — -never been out ; 
31 took the ration and found it beneficial. 

1 Patient claiming to be a Heavy Drinker, and this one 
took the ration and made no comment. 

^^ Allowing for possibilities of error, I should say that at 
/ least 60 per cent, of the 147 cases of war neurosis admitted 
to the Maudsley Hospital were total abstainers, which is 
a percentage double of that of the 62 cases admitted to 
Ruskin Park suffering with w^ounds or diseases other than 
functional nervous conditions. 

The high percentage of total abstainers among cases of 
war neurosis and shell shock was associated with fear 
of the consequences of drink, or a dislike of the taste of 
drink, consequently refusal to take the rum ration. Fear 
of the consequences, in a great number of instances, was 
due to the results in the home of paternal drunkenness, 



224 WAR NEUROSES AND SHELL SHOCK 

and in fewer instances of maternal drunkenness, or 
drunkenness in both parents. 

It will be observed that a number of total abstainers 
admitted that the rum ration had been beneficial, and 
that they had- taken it when they had to " stand to " in 
the trenches wet and cold in the early morning, prior to 
getting over the parapet for an attack. 

Moreover, I questioned a number of officers of all ranks, 
even including advocates of temperance, and with very 
few exceptions they were convinced of the value of the 
rum ration, if it were given out by an officer who saw that 
no soldier obtained more than his ration. They emphasised 
its utility as a stimulant when the men were wet and cold 
and had to stand to at dawn ; it put the feeling of warmth 
in them, and gave them the necessary stimulus and ardour 
to go over the parapet for an attack. The general recom- 
mendation was to give it in the tea, and the men preferred 
it so ; only a few cared for it neat ; it was too strong. 
Many officers and men were of the opinion that on return- 
ing to billets, cold and wet through, a rum ration produced 
a comforting feeling and promoted sleep. 

Alcohol thus judiciously employed may by its psychic 
effects be of undoubted benefit in warfare. It is well 
here to refer to the conclusions of the Advisory Committee 
of the Central Control Board (Liquor Traffic), " Alcohol, 
its Action on the Human Organism," of which the author 
was a member. The main effects of alcohol that have 
any real significance are due to its action on the nervous 
system. So far as direct action is concerned, alcohol when 
administered in moderate doses, in dilute form and with 
sufficient intervals, has no effect of any serious and prac- 
tical account. The action of alcohol is not really a stimu- 
lant to the nervous system, but a sedative to the highest 
centres of control, and acts by causing a decrease of critical 
self-consciousness and anxiety. 

" When stimulation of nervous function is really needed, 



ALCOHOL AND WAR NEUROSES 225 

and when the individual has to meet an emergency which 
calls for the exercise of his highest powers of perception 
and judgment, alcohol is not merely useless, it is certainly 
and unequivocally detrimental. On the other hand, there 
are emergencies when, though the individual may also 
imagine that he needs to be braced up nervously, he would 
be assisted far more by a relaxation than by an increase 
of tension ; and here the sedative action of alcohol, so far 
as the immediate effect is concerned, may be advantageous. 
The value widely attributed to the rum ration, under the 
conditions of acute discomfort, cold and strain, inseparable 
from trench warfare, may be explained in this way." 

History repeats itself, for so early as the reign of 
Edward III, Raymond Lulli, the inventor of the Universal 
Art, had great faith in " the marvaylous use and com- 
moditie of burning waters, even in warres, a little before 
the joining of battle, to styr and encourage the souldiours' 
mindes." 



Alcohol as a Food 

" Men do not as a rule take alcoholic beverages because 
they regard them as a ' food,' nor do those who abstain 
from these drinks do so merely because they doubt their 
food- value. The use of alcohol is dictated by the fact 
that, to the majority, the taste of alcoholic beverages and 
the immediate effect of alcohol are agreeable, and that 
the pleasure desired therefore outweighs their estimate of 
remoter harm." 

The moderate use of alcohol by the many, however, is 
inseparably associated with or leads to abuse by the few, 
with all its attendant evils. 

Relatively few cases of soldiers and non-commissioned 
officers direct from overseas suffering with chronic alco- 
holism have been admitted to the Maudsley Neurological 
Clearing Hospital. The percentage of cases of acute and 
Q 



226 WAR NEUROSES AND SHELL SHOCK 

chronic alcoholism among officers admitted under my care 
has been higher than the percentage from the ranks. 

Alcoholics are often returned as suffering with neuras- 
thenia; or their drinking propensities have been dis- 
covered while on leave from active service by crimes or 
misdemeanours ; or while undergoing treatment in hos- 
pital they have absented themselves without leave, re- 
turned to hospital intoxicated, or been sent or brought to 
the hospital in a state of acute alcoholic intoxication, or 
even in a state of delirium tremens. 

An inquiry into the family and past personal history of 
cases of acute and chronic alcoholism showed that in many 
cases there was an inborn mental instability which pre- 
disposed an individual to drink. It is always difficult to 
decide the relative importance of the predisposing cause 
and opportunity. In some cases the family history showed 
that alcoholism, suicide, neuroses and psychoses affected 
antecedents in varying numbers, while in others no such 
history was obtainable, and the habit seems to have been 
acquired in early life as a result of convivial imitation or 
to drown dull care. Not infrequently the history showed 
that a brilliant career has been destroyed by the habit 
having become a vice over which the individual has lost 
complete control. Enfeebled will and power of concen- 
tration, failing memory and loss of moral sense, become 
manifest by carelessness, broken promises, lack of auto- 
critical faculty, neglect of duty, and unreliability in speech 
and conduct. Attacks of despondency, followed often by 
bouts of drinking which were attended either by boasti'ul 
loquacity and quarrelsome excitement in which the in- 
dividual became dangerous to others {vin gai), or the reverse 
happened, and the patient became maudlin, sentimental, 
tearful, perhaps depressed and suicidal {vin triste), accord- 
ing to the temperament of the individual. 

Norman states that the number of cases among the 
soldiers in which suicide has occurred is disproportionately 



ALCOHOL AND WAR NEUROSES 227 

great in comparison with those observed in ordinary times. 
Cut throat has been by far the most common method in 
this condition, as in suicidal attempts in general. Major 
Hotchkiss notes that of the forty-five cases of cut throat 
admitted to Dykebar Military Hospital during a year, 
eighteen were the subjects of alcoholism. " Many of these 
attempts were made during an acutely confusional stage, 
and later there was no recollection (or apparently none) 
of what had taken place. In others it was associated with 
intense depression, which alcoholic excess produces in 
certain individuals." 

A quantity insufficient to affect the normal being is 
enough to render the individual with an invalid brain 
anti-social, consequently cases of shell shock, mental 
deficiency, neurasthenia, epilepsy, and especially head 
injury are very susceptible to the toxic effects of alcohol. 
According to the experience of Major Hotchkiss at Dykebar 
Asylum, between cases of delirium tremens and the chronic 
delusional form of alcoholic insanity are those cases which 
show such varied symptoms as mental confusion, depres- 
sion, subacute excitement, and in practically all cases 
hallucinations. " The history of many of these cases 
suggested that though alcoholism was a prominent feature 
in predisposing to a mental breakdown, of still greater 
importance was the stress and strain of the campaign, 
and had it not been for this the breakdown would never 
have occurred or would have been postponed." Probably 
the family history in many of these cases of alcoholic 
hallucinosis would show an inborn neuropathic tendency. 

According to my experience, and also according to the 
experience of most authorities, symptoms of chronic alco- 
holism and of alcoholic insanity have been found among 
the older men, and especially those serving in Labour 
Battalions, or that have been employed permanently at 
the base, where they have more opportunities of indulging 
in alcohol to excess. In the majority of cases of chronic 



228 WAR NEUROSES AND SHELL SHOCK 

alcoholism the symptons were auditory hallucinations and 
delusions of persecution. As in civil life, delusions of 
conjugal infidelity were common. 

One elderly officer, a chronic inebriate, came under my 
care, and he had delusions of conjugal infidelity and visual 
and auditory hallucinations of a man " he had done in " 
whom he imagined had been the cause of his wife's un- 
faithfulness. This patient also exhibited a considerable 
degree of mental confusion, amnesia and coarse tremor; 
in addition there was muscular weakness of the legs, 
absent knee jerks and tenderness on pressure of the calves. 
A fairly typical Korsakoff psychosis with polyneuritis. 

There is no form of alcoholism or alcoholic insanity 
which may not be met with, and the hallucinations and 
delusions, as in other forms of insanity, may be coloured 
by the conditions of warfare. If we consider the tempta- 
tion that there is to drink during periods of great stress 
and anxiety when opportunity occurs, it is remarkable 
that more cases of alcoholism do not occur in the fight- 
ing line. Much more drink is, however, consumed during 
the suspense and inactivity in billets and camps, also 
during leave. All the evidence points to the fact that 
intemperance has in the past played a not inconsiderable 
part in the production of military inefficiency, especially 
in officers. The necessity of controlling and limiting the 
sale of alcoholic beverages has been brought home to the 
Government by war emergencies, and the greatly diminished 
consumption has made not only for military but for 
national efficiency. It is to be hoped that control of the 
liquor traffic will remain permanently in force after the 
war, and thereby help to solve a great social and economic 
problem. 

Carbon Monoxide Gas Poisoning 

The examination of a brain from a fatal case of shell 
shock led me to the conclusion that the man might, while 



CARBON MONOXIDE POISONING 229 

lying unconscious, have been exposed to gases resulting 
from incomplete detonation of some explosive. For I 
found throughout the white matter punctate haemorrhages 
quite similar to those which I had found in pre-war times 
in cases of fatal carbon-monoxide poisoning. I drew 
attention to this in the Lettsomian Lectures on " The 
Effects of High Explosives upon the Central Nervous 
System." Subsequent observations have shown that 
carbon-monoxide poisoning in modern warfare is a very 
serious and fatal accident, which happens much more 
frequently in a war like the present, where mines and 
countermines are continually employed on a gigantic 
scale, than formerly. It was well known that explosives 
under certain conditions owing to insufficient combustion 
(as in confined spaces) produce carbon monoxide. The 
French military authorities have long recognised the 
danger of " I'enivrement de poudre." The Crairae disaster 
in 1885 well illustrates this fact. A monster blast of gun- 
powder in a quarry attracted a number of persons from 
Glasgow to the site. Twenty minutes after the explosion 
a hundred onlookers collected in the quarry; forty were 
rendered immediately unconscious; others fell down in a 
state of giddiness. Of the forty seriously affected, six 
died : some of those who recovered developed convulsions 
on regaining consciousness; in others there was delirium, 
after which the patients became drowsy and slept. No 
secondary complications occurred, but in all there was great 
prostration and a long period elapsed before they regained 
their strength. 

Pre-War Knowledge of the Pathology of GO Gas 

Poisoning 

The most frequent cause of gas poisoning in civil life 
is that due to carbon monoxide (CO) ; it is a frequent form 
of suicide, and mine disasters are responsible for many 
deaths from this gas. It percolates through the soil and 



230 WAR NEUROSES AND SHELL SHOCK 

causes fatal poisoning. Being an inodorous gas and de- 
pending for its toxicity on its affinity for the haemoglobin 
of the blood, for which it has an affinity two hundred times 
as great as oxygen, it follows that a man working in an 
atmosphere contaminated even with a small quantity of 
this gas, suffers with deoxygenation of his blood. When 
a man has been exposed some hours to an atmosphere 
containing more than 0'02 per cent, of CO, symptoms of 
poisoning will appear. A man can bear without serious 
inconvenience, for half an hour or more, an atmosphere 
containing from 0*05 to O'l per cent., but 0*2 to 0*3 per cent, 
is dangerous. 

An interesting example of the value of the canary and 
the insidious origin of the CO poisoning came under my 
notice some years ago. Several cases of CO poisoning 
occurring amongst the female chorus-singers of the Italian 
Opera were admitted under my care to Charing Cross 
Hospital — they all recovered. One was severe enough to be 
kept in the hospital, and I saw her the next morning. Her 
blood did not give the carbon-monoxide reaction. A dead 
canary was brought with the patient from a house in 
Covent Garden, and the following history was given. The 
inmates of the house noticed the canary fluttering about 
and then falling off its perch dead, at the bottom of the 
cage; whereupon, suspecting gas poisoning, they left the 
house. The source of the CO was an electric cable under 
the house, which had fused, and th£ slow combustion of 
the bitimien that surrounded it had produced the CO, and 
this had percolated through the soil into the house. 

Petrol or gasoline engines in submarines, in which there 
was insufficiency of air, were known to be dangerous on 
account of the production of CO, and white mice were 
recommended by Dr. Haldane to be kept in these boats 
for the purpose of demonstrating the existence of this gas 
in the atmosphere. For, as in the case of the canary, 
these small animals are extremely sensitive to the poisonous 



CARBON MONOXIDE POISONING 231 

influence of this gas, doubtless due to the fact that in such 
small creatures the respirations and the rate of the heart- 
beat are extremely rapid; 0*25 per cent, affects a canary 
in one minute, and in three minutes it falls off its perch. 
They are therefore utilised in military operations connected 
with mining, or in detecting the existence of the gas in 
dug-outs, craters, trenches, and mine shafts. 

CO may be detected in the air also by the decolourising 
effect which it has on a solution of palladium chloride. 
According to Marshall, so little as 0-04 per cent, can be 
detected with certainty by this method. 

Illuminating Gas 

Cases of poisoning occur as the result of an escape of 
this gas, which contains carburetted water-gas. 

The amount of CO in illuminating gas varies very con- 
siderably in different towns; it may amount to as much 
as 50 per cent., and is then, of course, highly dangerous. 
If it were not for the fact that other gases, having a dis- 
tinctly unpleasant odour, are present in illuminating gas, 
the admixture of water-gas would be attended with much 
more frequent fatal consequences than it is at present. 
The danger of CO poisoning occurs in many occupations, 
e. g., in the process of making carbonyl of nickel. Some 
years ago I had the opportunity of studying the pathology 
of CO poisoning, especially that relating to the changes 
in the central nervous system, and of correlating the clinical 
symptoms manifested during life with the histological 
changes in the organs of the body and the central nervous 
system. These changes permit one to explain (in a measure) 
some of the more important clinical signs and symptoms 
met with during life in non-fatal cases which recover 
completely or are left permanently affected with symp- 
toms of nervous disease. As these investigations have a 
direct bearing upon CO poisoning occurring in war condi- 
tions, I will reproduce a summary of the results I gave in 



232 WAR NEUROSES AND SHELL SHOCK 

an introduction to the description of the brains in some 
cases of gas poisoning sent to me from the front.^ 



Pathology of GO Poisoning 

In 1907 I published in Vol. III. Archives of Neurology 
and Psychiatry, a paper on " Carbon Monoxide and Nickel 
Carbonyl Poisoning." I came to the conclusion that the 
nickel carbonyl poisoning was really due to the inhalation 







Fig. 56. — The right liemisphere of a worker at the nickel carhonyl 
manufactory, probably CO poisoning. Note the punctiform haemor- 
rhages in the corpus callosum, which have coalesced into hsemorrhagic 
masses at each extremity. 

of CO employed in the manufacture of nickel. Two such 
cases occurred of which I had the opportunity of examin- 
ing the central nervous system, and I found multiple 
punctate haemorrhages throughout the white matter of 
the brain, as can be seen in the photomicrographs. 

In this paper I compared the naked-eye and nnCioscopic 
appearance of the central nervous system in these cases 
of nickel carbonyl poisoning with those observed in a case 

^ Read before the Pathological Section of the Royal Society <>i M('<licino 
February 13, 1917. " 



PATHOLOGY OF CO POISONING 



233 



of suicide by illuminating gas, and I considered them to be 
identical in nature. I also reviewed in this paper the 
clinical symptoms and pathology of CO poisoning in respect 
to the findings in the central nervous system and especially 
the causes which occasioned the haemorrhages. All three 
cases died in from four to eight days with the complica- 
tion of pneumonia. Thrombotic occlusion of cerebral arteri- 



-Sn^ 


Mk 


^rv?l 


^Hk.° -^mip^ *^ 




VBip ,.' "* ^J^ ^^^^^^r^ 


' jBV 'ifl^^^ 


^^ 



Fig. 57. — Vertical sections through the hemispheres, showing coalescence 
of the punctiform haemorrhages in the corpus callosum and internal 
capsule, and throughout the whole of the white matter punctiform 
haemorrhages. 

oles or venules was considered to be the cause of the 
haemorrhages. 

In the case of suicide by illuminating gas, admitted 
under my care at Charing Cross Hospital, signs of cerebral 
haemorrhage occurred within twenty hours of commence- 
ment of the inhalation of the gas, for the limbs became 
rigid, and a plantar extensor reflex was obtained. At first 
the temperature on admission was 99° F., but when the 
rigidity of the limbs and the plantar extensor response was 



234 WAR NEUROSES AND SHELL SHOCK 

discovered six hours later, the temperature had risen to 
105 F., and the pulse and respiration had become very 
rapid. 

The nervous symptoms pointed to the occurrence of the 
punctiform hjemorrhages found post mortem in the internal 
capsules, and it may be assumed that the rise of tempera- 
ture might have been due to the toxaemia coincident with 
the onset of pneumonia ; for, when the patient died on the 




Fig. 58. — Photomicrograph of a section of the corpus callosum, 
showing the haemorrhages. (X 10.) 

fourth day, pneumonic consolidation was found. But it 
might have been due to the cerebral haemorrhages. Full 
notes of the clinical symptoms and post-mortem findings 
were reported. Microscopic investigation showed fatty 
degeneration of the heart, of the liver, and of the epithelium 
of the convoluted tubules of the kidney. 

Punctiform ha}morrhao( s. ,tf 1 1 ihult d to hyaline throm- 
bosis of small vessels of the wliite matter, have been de- 
scribed by Bignami and Nazari in various diseases, e.g., 
ajstivo-autumnal malaria, apoplexy, diplococcal meningitis 
following pneumonia and measles. It is possible, there- 



PATHOLOGY OF CO POISONING 



235 



fore, that pneumococcic toxaemia was productive of, or 
associated with, the causation of the haemorrhages in 
these cases of CO poisoning. 

But I am incHned to think that the CO poisoning alone 
would be capable of causing 
the jjunctiform haemorrhages 
for the following reasons : 
in both cases from the Nickel 
Works there was evidence 
of old haemorrhages in the 
form of minute round or 
oval punctiform patches of 
softening indicative of gas 
poisoning on some occasion 
previous to the man being 
obliged to give up work. 
And it was legitimate to 
attribute these symptoms 
they suffered from, viz. gid- 
diness, vomiting and head- 
ache (migrainous attacks), 
to the gas poisoning, causing 
congestive stasis and haemor- 
rhages. It is well to note 
that these migrainous at- 
tacks are frequently met 
with in men and officers who 
have been exposed to those 




Fig. 59. — Vertical section of a 
cerebral hemisphere of a woman 
who committed suicide by in- 
halation of illuminating gas. 
Death in four days. Spectrum 
of blood showed CO poisoning. 
There are punctiform haemor- 
rhages throughout the white 
matter which have coalesced in 
some situations, notably the 
corpus callosum (C.C.) and cen- 
trum ovale (CO.). 



conditions in which CO 

poisoning might have occurred without fatal results. 

From the facts observed in these three cases of CO 
poisoning, combined with certain anatomical conditions 
of the blood vessels supplying the white matter of the 
brain, to which I shall now direct attention, an explanation 
can be offered why these miliary haemorrhages are found 
in the white matter of the cerebrum and basal ganglia, and 



236 WAR NEUROSES AND SHELL SHOCK 

not markedly elsewhere in the brain (vide Figs. 56, 57, 58, 
59). It must be recognised that a combination of factors 
may arise in CO poisoning, viz. — 

1. The heart, owing to the anoxaemia, has to beat faster, 
and to do more Avork with less oxygen; consequently it 
may undergo fatty degeneration. 

2. There is microscopic evidence of an irritative and 
degenerative endothelial change in the cerebral capillaries, 
as shown by mitosis of the nuclei, and a fatty degeneration, 
made apparent by osmic acid staining. These changes 
may be due, as Lancereaux suggested, to CO in the serum, 
but aggravated by the pneumococcal toxin, which is also 
responsible for a tendency to increased fibrin formation of 
the blood, and to thrombosis in those vessels in which the 
anatomical conditions favour the lodgment of emboli, or 
clotting of the blood from congestive or inflammatory 
stasis. 



Miliary Haemorrhages in Gases of Shell Concussion 
and Gas Poisoning 

I may now mention that the microscopic appearances 
found in the brains of these cases of CO poisoning, dying 
with pneumonia respectively after four days, eight days, 
and seven days, were in all respects similar to the appear- 
ances presented by sections of certain brains received 
from France notified as dying of shell shock with burial 
{vide Fig. 15) and from gas poisoning; with one exception, 
and that only differed in the fact that a large part of the 
haemoglobin had been converted into chocolate-coloured 
pigment granules which blocked the small vessels in the 
haemorrhages (vide Plates I and II). 

Before proceeding to the description of these cases, 
attention will be directed to the anatomical relations of 
the vessels of the white matter of the cerebrum where 
these haemorrhages are found. 



PUNCTIFORM HEMORRHAGES 237 



Anatomical Relations of the Vessels favouring 
Capillary Stasis and Haemorrhage 

The pia mater covering the cortex sends dehcate-walled 
arteries and veins through the cortex to reach the subjacent 
white matter ; the arteries consist of short and long vessels 
which, after giving off fine branches to the interlacing 
capillary network of the grey matter, terminate in a brush 
of fine arterioles ; the short vessels end in this brush just 
below the cortex; the long penetrate deeper, to end in 
the corpus callosum and the centrum ovale. Each little 
artery breaks up into a tree, and forms a separate system 
of delicate arterioles. Each arteriole ends in a round or 
oval circumscribed area of capillaries, with an emerging 
vein. These veins do not anastomose. Thrombosis of 
arterioles or venules would therefore cause capillary stasis 
and haemorrhage into the brain substance in a circum- 
scribed area, also escape of blood into the perivascular 
sheaths of arterioles or venules; a condition generally 
found to occur where there are punctiform haemorrhages. 
Owing to the thin character of the walls of the arteries, 
it is difficult to decide whether a vessel in section is an 
artery or a vein. Punctiform haemorrhages are also found 
in great abundance in the brain structures supplied by the 
perforating arteries, especially those in which the opto- 
striate and lenticulo-striate branches terminate. These 
vessels give off relatively few branches until they reach 
their destination in the basal ganglia, and internal and 
external capsules; they then terminate in a brush of 
delicate-walled arterioles. Each vessel supplies, as in the 
case of the cortical vessels, circumscribed areas of capil- 
laries, and the result of embolism, or thrombosis, is the 
causation of similar small limited areas of haemorrhage 
and softening, which, when numerous, may become 
confluent {vide Figs. 56, 57). 



238 WAR NEUROSES AND SHELL SHOCK 



Shell Shock and Burial. GO Poisoning 

The brain of a man said to have died from shell shock 
was handed to me by Professor Keith for examination. 
The following notes accompanied this brain : Fatal case of 
shell shock with burial from Captain Armstrong, R.A.M.C., 
No. 7, Mobile Laboratory, B.E.F. Sent on from No. 1, 
Mobile Laboratory, No. 8 on Captain Armstrong's list. 








Fio. GO. — PlioloiiiieD^jraph ol section of coipus callo.suin from a case of 
probable gas poisoning, showing inflaniiTintory change around a small 
vein, a branch of which has ruptured. The deeply stained cells that 
are seen in the perivascular sheath are leucocytes. (X 200.) 

Brain of man, admitted unconscious, with history of 
having been buried by shell blowing in parapet. Remained 
stertorous for two days and died. 

Post mortem. — There is no wound of any kind on his 
body or head, and no visceral lesion. His ankle on one 
side was badly " sprained," but there were no fractures. 
The skull was unfractured, and no fracture of the base 
could be found. Brain shows multiple punctiform hsemor- 



CO POISONING AND SHELL SHOCK 239 

rhages, and some slight subpial extravasation {vide Fig. 15). 
No other particulars. 

Having regard to the fact that these punctiform 
haemorrhages and hyaline thromboses of vessels were 
identical in their microscopic appearances to those I had 
observed in CO poisoning, it occurred to me that the man 
may have been concussed, and afterwards gassed while 
lying unconscious and buried. In some sections of the 
brain there was evidence of inflammatory reaction around 
the small veins [vide Fig. 60). 

It may be argued that these punctiform haemorrhages 
were due solely to venous stasis and congestion, but I 
doubt this, for I have neither observed this condition in 
the number of cases of death from asphyxia, occurring in 
status epilepticus, nor after prolonged seizures of paralytic 
dementia, although I have examined the brains, macro- 
scopically and microscopically, in a great number of 
instances. 

A letter to me from the Trench War Committee con- 
firmed the possibility of CO poisoning occurring when a 
large shell burst in a confined space, such as a dug-out or 
a trench, if incomplete detonation of the explosive occurred. 
Moreover, it must be remembered that CO is odourless, 
and may percolate through the soil from a mine explosion 
for long distances into trenches or dug-outs without its 
existence being known {vide p. 252). 

In the Memorandum on " Gas Poisoning in Warfare," 
issued by the Director General, Medical Services, British 
Armies in France, in respect to CO poisoning, it is 
stated — 

" The lungs show no abnormal changes in cases of rapid 
death. Small punctate haemorrhages may be found in the 
white matter of the brain, and sometimes ecchymosis in 
the meninges, if the case has been exposed to a concentra- 
tion of CO sufficient to cause prolonged unconsciousness." 

The fact that CO is not found in the blood when the 



240 WAR NEUROSES AND SHELL SHOCK 

patient is examined does not prove that death was not due 
to CO poisoning, for after some hours of exposure to air 
it cannot be detected, and there is Httle opportunity to 
make the test for some hours or even days. 

Captain Dunn read an interesting paper at the Medical 
Society on Epidemic Nephritis, in which he showed hyahne 
thrombosis of the vessels of the alveoli of the lungs and 
of the glomerular capillaries of the kidney. In these 
cases he has observed multiple punctiform haemorrhages 
of the brain, which he attributed to embolism by hyaline 
thrombi. These hemorrhages present exactly the same 
appearances as in CO poisoning or gas poisoning. In a 
letter he has written to me, he states that he has now 
observed these haemorrhages in four more cases of neph- 
ritis, so that their occurrence in the first case was not 
fortuitous. " They are of quite similar appearance to 
those I have observed in phosgene poisoning." He asks 
whether haemorrhages of that type are seen in uraemia. 

Lieut. -Col. Elliott has forwarded me a memorandum by 
Captain H. W. Kaye with five autopsies on cases of poison- 
ing by drift gas (CL2 and C0C12), in which he describes 
blue-black dots in the brain of a sevent3^-hour case; he 
also refers to petechial haemorrhages in the stomach and 
evidence of blood destruction in the spleen. Lieut. -Col. 
Elliott also calls attention to the fact that Captain Henry 
was the first to describe thrombi in the renal vessels, and 
he disagreed with Dunn and McKnee when they described 
emboli as coming from the lungs. 

Examination of the Brain in Gas Poisoning 

I have recently had the opportunity of examining the 
brains of two cases of gas poisoning, in which gas was 
employed in an offensive by the enemy; and one is of 
special interest, because the whole of the white matter 
is peppered over with small dark spots about the size of a 



NEUROPATHOLOGY OF GAS POISONING 241 

pin's head. These are due to haemorrhages, but micro- 
scopic examination shows conditions which I have not 
found in CO poisoning, nor in other forms of gas poisoning ; 
in fact, I have never seen any condition hke this. The 
red blood corpuscles have been in large measure broken 
up, and the haemoglobin converted into dark chocolate- 
coloured pigment granules, which fill the capillaries, 




^5^^^^ 



'^.^ 







if^^' ' ^^^- ■■' "^ 



- ■•1e-*.4.-*>- ^^ 



. '■^^». 




jH^'-'lSm 



'^''ii' Mrife----- .: 



Fig. 61. — Punctate haemorrhages in corpus callosum from a case of shell 
shock and burial; very probably accompanied by gas poisoning 
while lying unconscious and buried. Observe the small white area 
in the centre of the haemorrhage, in the middle of which is a small 
vessel which, under a higher magnification, will be seen to contain 
a hyaline thrombus. (X 20.) 



arterioles and venules of the white matter of the brain. 
This is very possibly methaemoglobin, for it is known that 
exposure to nitrous fumes in concentration will oxidise 
the haemoglobin, and convert it into methaemoglobin. 
Phosgene COCI2 liberates HCl when it comes in contact 
with a moist surface; it is very irritating and would cause 
bronchiolitis. It is possible the free hydrochloric acid 



242 WAR NEUROSES AND SHELL SHOCK 

would convert the haemoglobin into acid haematin, and the 
altered blood pigment may thus be accounted for. 

Similar appearances were found to those described in 
CO poisoning, viz. multiple punctiform haemorrhages in 
the white matter {vide Fig, 61), but the blood corpuscles 
were intermixed with chocolate-coloured pigment granules 
pressed together by the haemorrhage at the side; on one 




Fig. 62. — ^Hyaline thrombus of vessel in cciitie of puiiclate haemorrhage. 
The thrombus was stained brown by dissolved pigment. Around 
the blocked vessel is a whit© area of brain substance containing 
numbers of leucocytes ; outside this is tlie haemorrhage, not very 
distinctly seen. The specimen was prepared from the subcortical 
white matter of the frontal lobe. ( X 346.) 

there is an aneurism filled with pink-stained thrombus 
{vide Fig. 63). Amidst the corpuscles are numbers of pig- 
ment granules. The low-power photomicrograph shows 
three haemorrhages with occluded vessels proceeding to 
them {vide Fig. 65). Nearly all the punctiform haemor- 
rhages show a central vessel, surrounded by an area of 
necrosed brain tissue, infiltrated usually with leucocytes. 
The whole of this area is stained pink by van Gieson 




Plate I. 



Section of optic thalamus, showing vessel blocked with 
pigment going to haemorrhage ; amidst the blood 
corpuscles are numerous pigment granules. To the left 
of the larger vessel are three capillaries packed with 
pigment and compressed together, (x 350.) 



NEUROPATHOLOGY OF GAS POISONING 243 

stain, and it is more or less difficult to make out the 
wall of the central vessel. Sometimes a capillary filled 
with a thrombus can be seen running to the central vessel. 
It may be filled with chocolate-coloured pigment granules 
probably embedded in a coagulum, as in Plates I and II, 




Fig. 63. — Li - mall perforating opto-striate arteries filled with pigment 

graniiles. Two of the arterioles show miliary aneurysms. (X 350.) 

or the coagulum may be of a pinkish-brown colour due 
to the coagulum being stained by the pigment dissolved in 
the serum {vide Fig. 62). In this, as in all other cases, 
there is evidence of an inflammatory stasis and excess of 
leucocytes in the vessels, and often into the perivascular 
sheath and tissues around. 



244 WAR NEUROSES AND SHELL SHOCK 




;..^ 



£. 



Brief Glinico-Anatomical Notes of this Case 

Brain. — Surface veins, large and small, distended with 
dark blue clotted blood (veins of base of skull were in same 
condition). Section shows thickly scattered blue-black 
dots throughout the brain, especially in the white matter; 

this applies also to the 
cerebellum, and to 
uuicli less extent to 
pons and medulla. 
Xo haemorrhage seen. 
Patient was admitted 
ten hours after being 
gassed, and died sixty 
hours after admission 
from bronchiolitis and 
failure of right heart. 

It is unfortunate that 
the clinical and post- 
mortem notes of this 
case are so scanty, for 
it is one of great 
pathological interest. 
The right heart failure 
and bronchiolitis, from 
which the patient died 
seventy hours after 
inhalation of the gas, 
would undoubtedly ac- 
count for the venous 
congestion and stasis noted post mortem and for the throm- 
bosis of the small vessels in the white matter of the brain. 
The blocking of the capillaries, small arteries and veins by 
the chocolate-coloured granules of pigment, especially of 
the capillaries, would however suffice to account for the 
haemorrhages. In some respects the capillary blockage 



Fig. 64. — Small vessel breaking up into a 
leash of small arterioles compressed 
together by the haemorrhage. The 
vessels are all blocked with black 
pigment granules. Specimen from in- 
ternal capsule gas poisoning. (X 70.) 




Plate II 

Small vessels blocked with pigment in haemorrhage, and to 

the right a larger vessel, probably a vein, filled with lightly 

brown-stained hyaline thrombus, (x 150.) 



NEUROPATHOLOGY OF GAS POISONING 245 



by pigment resembles the condition found in pernicious 
malaria, in which disease Bignami and Nazari have de- 
scribed punctate haemorrhage of the white matter of the 
brain; but I am inclined to believe the principal cause 
of the haemorrhages is inflammatory stasis and hyaline 
thrombosis of arterioles, capillaries and venules, the pig- 
ment granules being incorporated in the coagulum. 



-■i!^%ii' 





vNs.'t-~* 



Fig. 65. — Three punctate luemorrliages sliowing opto-striato arterioles 
filled with pigment granules. ( X 30.) 

Microscopic Examination of the Brain in Shell 
Concussion with Gas Poisoning 

I received the brain of another case in which the bruises 
on the body, the haematomata in the right lung, and the 
other conditions described, all suggest that he had been 
blown up by a shell and buried, and that the injuries of 
the brain were due to concussion. The fact that there was 
no CO detected in the blood does not conclusively prove 
that he was not exposed, while buried, to CO gas. 



246 WAR NEUROSES AND SHELL SHOCK 



Clinical Notes of this Case 

Admitted with diagnosis of shell shock. Purple bruises on 
arm and leg of right side. Stertorous, unconscious and during 
the night before death constant fits. Lived thirty hours in 
hospital. 

Post-mortem. — There were two ha^matomata in the right 
lung, but no other visceral injur5^ No haemorrhage of the scalp 
and no fractures of the skull. Some slight subpial haemorrhage 
of the right hemisphere. Fornix destroyed and full of ha-mor- 
rhages ; haemorrhages also seen in corpus callosum. Haemor- 
rhage in both optic tha'ami : cerebro spinal fluid tinged with 
blood. Men admitted with him said he had been buried by a 
shell. There was no CO in his blood, and the bruising was 
purple. 

Microscopic Examination . — Multiple punctate haemorrhages 
are seen ; hyaline thrombosis of capillaries, arteries and venules ; 
perivascular sheaths contain blood. Marked evidence of in- 
flammatory stasis. Some of the small veins are filled with 
blood corpuscles, one half of which are polymorphonuclear 
leucocytes, and in the perivascular sheath and tissues around 
are large numbers of polymorph leucocytes {vide Fig. 60). 



Examination of a Brain from a Case of Gas-Shell 

Poisoning 

Clinical Summary. — Unfortunately there are no notes of the 
condition of the reflexes nor the state of tonus of the muscle of 
the limbs. The clinical notes do not indicate that this patient 
suffered with pneumonia, nor any obstruction to the entrance 
of air to the lungs ; there is no statement regarding the cause 
of the extremely rapid respiration but the fact that he was 
given oxygen and diffusible stimulants for the first twelve 
hours suggests air hunger. Later there is a definite statement ; 
there is no evidence of cyanosis and no respiratory obstruction. 
The oxygen was stopped; but the respiration still continued 
very rapid, 50 to 60. 

After some days his condition greatly improved, and the 
respiration fell even to 28. Then on the last day, in the 
morning, he suddenly developed grave symptoms, and in 
the evening it is noted that he developed marked nystagmus, 
internal strabismus, and the right pupil was distinctly sluggish 
and slightly larger than the left. The conclusions and findings 
are not inconsistent with CO poisoning, although to my mind 




Plate III. 

Section of frontal cortex from case of shell gas poisoning. 
Hyaline thrombus of vessel in the centre of haemorrhage. 

(x 150.) 



NEUROPATHOLOGY OF GAS POISONING 247 

it is more likely to be due to phosgene. I was unable to con- 
firm the statement of haemorrhage into the pons and medulla. 
The vessels were congested, but no haemorrhage was found. 
The cerebral hemispheres were badly preserved, and I was only 
able to examine the cerebral cortex of the frontal lobes. 

Microscopic Examination. — Portions of the frontal cortex 
and subjacent white matter showing to the naked eye miliary 
punctiform haemorrhages were taken, and as in all the other 
cases blocked in paraffin, and sections cut and stained by van 
Gieson and haematoxylin eosin methods, also with polychrome. 
The punctiform haemorrhages appeared in some of the sections 
to form a circle of circumscribed, discrete, oval or round areas 
of extravasated blood, with often a section of a vessel in the 
centre or proceeding to the haemorrhage area. In sections 
stained by the van Gieson the lumen and the thin-walled vessels 
so seen appear a pale pink, and this is due to the contained 
hyaline thrombus {vide Plate III). 

In some vessels, red blood corpuscles are seen with abundant 
fibrin formation : a similar appearance to that seen in the 
alveoli in red hepatization; other vessels appear filled with 
polymorphonuclears and fibrin. Around the central throm- 
bosed vessels of the haemorrhage are seen deeply stained pink 
areas of necrosed brain tissue, infiltrated with polymorphonu- 
clear leucocytes ; very often a vessel can be seen filled with blood 
and extravasated into the sheath, and occasionally the rupture 
of a thin-walled vessel causing haemorrhage into the perivascular 
sheath can be seen. This condition of central thrombosis with 
necrosis of brain tissue around, and infiltration of leucocytes, 
is similar to that observed in the CO poisoning from the nickel 
works, when the patient lived eight days, and is in accordance 
with what might be expected, seeing that the man lived six 
days after inhalation of the gas. 



Summary 

The reason why these punctiform haemorrhages occur in 
the white matter of the brain is primarily due to the 
anatomical condition of the vessels in the white matter 
of the cerebrum, where the arteries are terminal; each 
small artery having a separate capillary system, likewise 
the emerging veins. A tendency to stasis may be brought 
about in these separate vascular systems by the failure 
of the heart as a force pump and suction pump, also by 



248 WAR NEUROSES AND SHELL SHOCK 

those respiratory conditions which lead to right heart 
dilatation and interference with the return of blood from 
the skiill.i In the gas case, in which the haemoglobin has 
been converted into pigment granules, it seems probable 
that the haemorrhage may be accounted for by occlusion 
of the arteries. In most cases the two factors are com- 
bined. It seems probable, however, that either cause 
may act independently in causing inflammatory stasis and 
thrombosis, resulting in multiple punctiform haemorrhages. 
It is unfortunate that with the exception of the case of 
CO poisoning by illuminating gas, I have not had the 
opportunity of examining the organs of the body. 

It is quite probable that, as in that case, fatty degenera- 
tion of the heart, the kidneys, liver and vessels of the brain 
would be found to exist. 

The symptoms of chlorine gas poisoning are as follows : — 

Severe cough, spasm of the glottis, and if the concentra- 
tion reaches one in ten thousand and continuance of the 
inhalation occurs, the struggle for breath becomes very 
acute. 

The symptoms observed in men who were gassed with 
chlorine were due mainly to the irritating effects upon the 
respiratory passages causing coughing, choking, violent 
efforts to breathe and, in spite of their efforts, a progressive 
cyanosis and signs of asphyxia. 

Added to the torture of the struggle for breath, is great 
soreness and pain in the chest. In some cases the asphyxial 
cyanosis gave place to a deathly pallor, and collapse due 
to cardiac failure occurred. 

Phosgene gas, COClg, was used by the Germans in their 
second gas offensive, as it does not cause the same acute 
bronchial irritation that chlorine does; it is able to pene- 
trate the bronchioles and alveoli of the lung, and excite 

1 Dr. Sidney Coupland many years ago showed a brain with puncti- 
form hfemorrhages, the result of asphyxial conditions consequent upoa 
capillary bronchitis and heart failure. 



IMPERFECT DETONATION OF EXPLOSIVES 249 

an inflammation. Therefore, although its immediate effects 
are not so severe, it is more deadly in its ultimate effects. 

Gas Burning in Mines and from Imperfect Detona- 
tion or Burning of Explosives in the Operations 
of War 

Carbon monoxide is a gas which is especially dangerous 
when mines are exploded, or when there is imperfect de- 
tonation or burning of explosives, for the following reasons : 
it is inodorous ; it can percolate through the soil without 
being absorbed or decomposed; it may be found in large 
quantities; it is cumulative in its effects on account of 
its affinity for the haemoglobin of the blood; small per- 
centages in the atmosphere in time will produce as marked 
poisonous effects as large percentages ; indeed, cases of 
CO poisoning by long exposure to an atmosphere con- 
taining small percentages suffer with more severe nervous 
symptoms. 

As I have ascertained, a man may be gassed by CO, 
causing nervous symptoms which are not recognised as 
being due to the gas, and, subsequently he is again exposed 
to the poisonous atmosphere and succumbs. The nervous 
system shows that the dizziness and migrainous symptoms 
with which he first suffered and which were disregarded, 
were associated with definite changes in the brain as 
revealed by lesions of a more advanced nature than the 
recent punctiform haemorrhages associated with the second 
exposure. 

It is generally believed that the poisonous effects of CO 
are entirely due to the combination of the gas with haemo- 
globin, and in proportion to and entirely dependent upon 
a deoxygenation process; in fact, it produces anoxaemia. 
I do not think this fully accounts for all the symptoms, 
although it does for those in cases which recover upon 
reoxygenating the blood by the administration of oxygen 
and artificial respiration, even though brought out in a 



250 WAR NEUROSES AND SHELL SHOCK 

state of unconsciousness. But why do they not recover 
with this treatment? What causes death? The answer 
may be that the cardio-respiratory centres of the medulla 
fail and the heart and diaphragm cease to act. One 
thing we do know is, that any exertion causing a more 
rapid and energetic action of the heart and diaphragm is 
liable to terminate fatally. 

Fatal cases exhibit a fatty degeneration of the heart, and 
probably, as in pernicious anaemia, where there is a de- 
ficiency of oxygen, fatty degeneration of the diaphragm as 
well as of the heart occurs. 

The recent work which has been done on oxydases, 
shows that thickly disseminated throughout the grey 
matter of the central nervous system (and not the white 
matter) are fine granules of oxidase ; these are also seen 
in muscles and leucocytes, in fact in all living tissue where 
active chemical changes are taking place. We do not 
know what effect CO may have upon these oxidase 
granules. They may have an affinity for CO; possibly 
prolonged exposure to a small percentage in the atmo- 
sphere may be attended with more serious effects in the 
nervous system on account of a dissociation of the oxidase 
in the grey matter. At present this is speculation, but it 
may serve to account for some of the severe symptoms 
that attend some cases of CO poisoning which will be 
considered in detail later. 

Causes of Explosives Producmg Poisonous Gases 

Although theoretically most of the carbon in explosives 
should undergo complete combustion, this by no means 
always happens. 

Under certain conditions all explosives, whether high or 
low, are liable to give off noxious gases. Practically 
speaking, the only poisonous gas that demands attention 
is CO ; for although nitrous fumes are Uable to be formed, 



CAUSATION OF CO POISONING 251 

as a rule they exist in such small quantities as to be negli- 
gible. When they exist in larger amounts they are readily 
recognised by their irritant action and odour; moreover, 
they are absorbed in a damp soil. 

Some explosives produce more CO than others, thus 
gun-cotton produces a large amount even when there is 
complete detonation. All explosives in the presence of 
moisture are liable to produce CO. Certain high explosives, 
of the ammonium nitrate group, for example ammonal, 
are very hygroscopic in the presence of the least moisture, 
and produce then large quantities of CO. The explosives 
of this group employed by the Germans all produce abun- 
dance of CO. Deterioration of the charge by absorption 
of moisture may lead to incomplete detonation and pro- 
duction of abundance of CO. Thus damp workings, 
especially in permeable soils, are exceptionally dangerous 
for mining operations, particularly now that enormous 
charges are used. . 

How GO Poisoning Gases are Gaused 

When a camouflet is formed by an explosion there is 
danger of a pocket of gas being formed; this may con- 
stitute a danger to galleries long after the explosion has 
occurred. When a crater is formed by an explosion of a 
mine the noxious gases escape. 

A clay soil is less dangerous for mining operations than 
a permeable soil. CO poisoning has occurred from escape 
of gas in an old working; the gas may take the most 
peculiar directions, and after percolation through the soil 
it is odourless. Men are liable to suffer from CO poison- 
ing on this account when a small mine is exploded near 
a gallery, for no notice is taken, as no physical effects are 
produced, but the gas is not able to escape and percolates 
through the soil; then by its cumulative effects upon the 
occupants of the adjoining gallery symptoms of gas poison- 



252 WAR NEUROSES AND SHELL SHOCK 

ing are produced. A sapper under my care told me that the 
enemy exploded a mine, and he and another of a party of 
seven, who were working in a gallery near by, were the 
only men taken out alive. He had been a miner prior to 
the war, and said, " The gas came through into the sap." 
While in the field hospital, and after he had regained 
consciousness, he saw one of the bodies ; it looked as if 
the man was alive, the cheeks and lips were pink. The 
symptoms he suffered with were vomiting, pain at the pit 
of the stomach, breathlessness, palpitation increased by 
any exertion, and for some time a splitting headache. 
When under my care the principal symptoms were of an 
emotive character, viz. tremor of the lower extremities 
and exaggerated deep reflexes with headache, dizziness, 
and insomnia, all of which were of psychogenic origin. 

The trenches near a mine, especially if they are narrow 
and (owing to atmospheric conditions) badly ventilated, 
may, on explosion of an enemy mine, contain enough CO 
in the atmosphere to cause poisoning. A man who is 
concussed and buried by shell fire in a trench thus poisoned 
with CO may suffer not only with shell shock, but he may 
be gassed at the same time. 

Again, soldiers who have taken refuge from shell fire 
in dug-outs, mine shafts, chambers, and mine craters after 
the explosion of a mine, have been gassed, and infantry 
are warned of the danger of these death traps. 

Other causes of gas poisoning from incomplete com- 
bustion may be mentioned, viz. compression plants for 
ventilating mines, when, if impure mineral oil is used as 
a lubricant, CO may be formed in sufficient amount to 
constitute a danger. Gas may be formed also from the 
use of petrol engines in a confined space. Three men 
slept on the staircase of a large dug-out where there was 
a petrol engine used for illuminating the place; they all 
suffered with gas poisoning, and one of them subsequently 
came under my care. 



SYMPTOMS OF CO POISONING 253 

The engineers are fully aware of all the dangers of poison- 
ing by this gas, and instructions are given to them as to 
prevention and treatment of such cases when they occur. 

Explosives like T.N.T. give rise to considerable quantities 
of hydrogen and methane, which are inflammable, and 
fires may result from their explosion ; explosions of these 
gases in mines is one of the causes of the production of 
considerable quantities of CO. 

Symptoms of GO Poisoning 

As in cases of shell shock, so in CO poisoning, the psycho- 
genic factor comes into play in cases of gassing; this 
has been strikingly apparent when a large number of men 
have been subjected to CO poisoning by a mine explosion. 
Still, there are certain symptoms which may be directly 
attributed to the anoxaemia. 

When small percentages of CO in the atmosphere are 
inhaled for a considerable time the onset of symptoms is 
gradual and insidious. The first symptoms are related 
to cortical anoxaemia, viz. headache, vertigo, noises in 
the ears, deep sighing or yawning, with weariness and 
blurring of vision ; followed later by mental depression, 
mild delirium with visual hallucinations, due to cortical 
dissociation, and eventually unconsciousness. 

There is usually dyspnoea and palpitation, owing to the 
effects of lack of oxygen on the cardio-respiratory centres. 
Exerti'on will cause the oxygen available to be rapidly 
used up and hasten the onset of unconsciousness. 

In some, there is a feeling of utter loss of power in the 
lower extremities, and when men have to be rescued from 
a mine they must be roped, or they will fall back into the 
mine shaft. 

In other cases there are sensory disturbances, and the 
rungs of the ladder by which they are endeavouring to 
escape may feel two or three times their actual size. It is 



254 WAR NEUROSES AND SHELL SHOCK 

remarkable that when they reach the surface and are 
exposed to the fresh air loss of consciousness frequently 
supervenes. 

Sometimes the onset of symptoms is marked by languor, 
or a drowsy lethargy with an irresistible desire to rest. 
There is a feeling of cold and shivering, due to lowering of 
the body temperature, and it is easily understood why men 
who have been poisoned with CO rapidly succumb to 




Fig. 66. — Sections of medulla oblongata from case of gas poisoning, 
stained by Nissl method, showing the swollen cells of the nucleus 
ambiguus. Observe the enlarged, clear, eccentric nucleus ; the sur- 
rounding cytoplasm shows an absence of Nissl granules. In not 
a single cell is the nucleus seen in the centre, as it should be. ( X 350.) 



pneumonia, especially if there is the additional cause of 
exposure to cold and wet in the trenches. 

Cheyne-Stokes breathing, when it occurs, is a fatal omen, 
owing to the affection of the medullary centres (vide Fig. 66). 
The pulse, at first of normal rate or only slightly accelerated, 
becomes weak and rapid and the blood pressure falls. 
After death the face may appear life-like; the cheeks 
and lips being a cherry-red even when life is extinct; or 
there may be deathly pallor of the face and cold sweat. 



SYMPTOMS OF CO POISONING 255 

After-effects of GO Poisoning 

The nervous system and the heart are especially likely 
to suffer, and the post-mortem changes which I have 
described as occurring in fatal cases explain the persistence 
of the symptoms,, which are, however, not due to persist- 
ence of CO in the blood, for it cannot be detected some 
hours after removal to the fresh air, and especially if 
oxygen has been administered. When men affected 
regain consciousness they appear dazed and stupid, and 
generally have no recollection of what has happened; 
there may be considerable mental confusion. Some look 
as if they were recovering from a drunken bout. The 
slightest excitement or cause for anxiety will bring on a 
return of the symptoms complained of, such as palpitation, 
precordial discomfort, tightness and oppression in the 
chest, pains and feelings of distress in the head, while 
beads of perspiration may appear on the forehead, and the 
facial expression assumes a look of anguish. 

The effects on the nervous system may persist for some 
time, and are shown by a dazed, confused mental state; 
in some the speech is slow, hesitant, or slurred, and there 
may be a tendency to repetition of syllables or words; 
others, again, are listless, drowsy, and apathetic; while 
others may develop a maniacal excitement, fighting, 
laughing, shouting, and struggling. Nearly all cases 
suffer with intractable and persistent headaches. Fre- 
quently there are gastro-intestinal symptoms, viz. vomit- 
ing, hiccough, pain, and sinking feeling at the epigastrium. 
But of all the symptoms the most serious and persist- 
ent are the cardio-vascular ; there is a breathlessness 
on exertion, precordial distress and discomfort, throb- 
bing of the vessels in the neck, palpitation, and rapid 
pulse aggravated by slight exertion ; there may be palpable 
evidence of cardiac dilatation. These symptoms are 
undoubtedly to be associated with fatty degenerative 



256 WAR NEUROSES AND SHELL SHOCK 

changes of the heart muscle, and it is not to be wondered 
at, therefore, that many months may elapse before the 
patient recovers from these distressing symptoms. 

Disturbances of the nervous system are most marked, 
and are manifested by amnesia anterograde and retro- 
grade in severe cases ; paramnesia ; mental enfeeblement ; 
loss of power of concentration, and ready fatigability. 
Symptoms, indeed, are so much like some cases of severe 
shell shock that one is inclined to think some of the cases 
of severe shell shock with burial are really complicated 
by CO poisoning. This seems all the more likely, in view 
of the fact that I have described cases of shell shock with 
burial in which there were punctiform haemorrhages in 
the white matter exactly like those seen in CO poisoning, 
whereas in two cases of uncomplicated shell shock I found 
no punctiform haemorrhages. As a rule, these symptoms 
pass off in time, but occasionally they may last years. 

I was consulted by, and saw on several occasions sub- 
sequently, a naval officer of great promise, who in the 
early days of the submarines was gassed with other sailors. 
He developed an acute maniacal condition; then lost his 
speech for a time and became quite demented. Years 
passed, and he still showed a marked amnesia of all that 
he had learnt prior to the accident. 

Cases have been described which presented features like 
those of disseminated sclerosis, and this is not surprising, 
seeing that widely-scattered punctiform haemorrhages may 
occur through the white matter of the brain, which, when 
coalescent, would constitute considerable-sized areas of 
sclerotic degeneration. 

Sensory disturbances of various kinds may result, and 
a neuritis may be the cause. It is remarkable that the 
deltoid muscle is picked out, and it has been noticed that 
the right is more likely to be affected than the left, probably 
because the right arm is used more than the left; the 
groups of extensors are more affected than the flexors. 



PREVENTION OP GAS POISONING 257 

As in shell shock, the personality of the individual plays 
an all-important part, nor can the psychogenic factor be 
underestimated. 

Prevention of Gas Poisoning and Accidents in Mines 

Underground warfare by means of mines and counter- 
mines charged with high explosives in quantities which, 
prior to this war, would have been regarded as incredible, 
has necessitated the enforcement of rules for prevention 
of gas poisoning of the troops, not only of the sappers 
actually engaged in mining, but of the infantry. Among 
the more important precautions which are laid down in 
the Army Orders are the following : — 

1. When a blow occurs, even though this appears to 
be a long way off, all men working underground must at 
once come up. 

2. No man should be permitted to descend the shaft 
of a mine without rescue apparatus till the mine is reported 
clear of gas. No man is permitted to ascend the shaft 
without being roped. 

3. Infantry are forbidden to take part in rescue opera- 
tions. Only men who know the dangers and have been 
trained to overcome and avoid them should be allowed to 
constitute rescue parties. 

The gas helmet and box respirators issued to the army 
for the protection against chlorine and phosgene offensive 
gas are useless in prevention of CO poisoning. Special 
helmets and gas masks are employed. The presence of 
CO in the air can be readily detected by the effect of an 
atmosphere suspected of containing CO upon canaries 
or mice. These small creatures are affected in a few 
minutes; the former are more useful than the latter. 
A cage containing a canary with three sides of wire is 
carried into the mine gallery or dug-out, and from place 
to place, so as to sample the air in different situations. 
If there is CO in any poisonous percentage in the air, the 



258 WAR NEUROSES AND SHELL SHOCK 

bird will ruffle its feathers in a minute or so, flutter, and 
in two or three minutes fall off its perch. The beat of 
the heart of the canary is 750-1000 per minute, and this 
rapidity of the heart action and circulation accounts for 
the rapid action of the poison; for the same percentage 
of CO in the atmosphere that produces effects upon the 
canary in two or three minutes will take at least half an 
hour to affect a man. Therefore, in any atmosphere 
which will cause serious symptoms of poisoning, the canary 
test will give amples. warning long before the gas has any 
effect on the men. . 

Treatment 

If the man has ceased breathing, artificial respiration 
should be immediately resorted to by Schafer's method. 
Oxygen should be administered, the temperature should 
be maintained by warm bottles, hot bricks, and blankets. 
The stimulants that should be employed are hot strong coffee 
and hypodermic injections of strychnine. Alcohol should 
not be given. Every possible endeavour should be made 
to avoid exertion; for this may cause death from heart 
failure. No man who has been gassed and restored should 
be allowed to march back to the trenches. 

The rationale of the preventive measures against gas 
poisoning, and the treatment which should be adopted 
when it has occurred, is obvious from a consideration of 
the facts stated in the previous pages. 

The Ejects of Irritani, Gases upon the Brain 

I have dealt at length with the subject of CO and 
Phosgene poisoning, as I have had the opportunity of 
examining the brains of fatal cases, but latterly a great 
number of men have been evacuated on account of ex- 
posure to irritant gases from shells charged with chemicals. 
Of these gases the so-called Mustard Gas (Di-ethyl-clilor- 
sulphide), on account of its pungent and irritating effects 
upon the skin and mucous membranes, is the most 
important. 



EFFECTS OF IRRITANT GASES 259 

This means of offensive has been most extensively used 
by the enemy ; it is not within the scope of this work to 
do more than allude to the irritating effects on the mucous 
membranes of the respiratory tract, causing a pharyngitis, 
laryngitis, tracheitis and bronchitis for which the soldiers 
may be evacuated. Grafted on to these physical inflam- 
matory conditions may be neurotic signs and symptoms. The 
man so affected, especially if he be a subject of constitu- 
tional neurosis, may develop neurasthenic and hysterical 
manifestations. The laryngitis may cause aphonia and 
mutism, and the idea that he can only speak in a whisper 
or that he is dumb becomes fixed in his mind. 

Numbers of these cases have been sent to me, and 
have been cured with great ease and rapidity by physio- 
psychotherapy. The voice sometimes remains hoarse on 
account of a chronic laryngitis. The treatment of the 
inflamed pharynx and larynx by inhalation is very useful 
in the early stages when there is visible evidence of chronic 
inflammation, but its continuance on account of the 
neurosis is prejudicial to recovery, because it suggests a 
physical basis for a functional nervous condition. The 
inhalation which is recommended is Tinct. Benzoin §i, to 
which Menthol gr. x is added. One teaspoonful of this is 
added to a pint of boiling water, and the vapour inhaled. 

Another common hysterical symptom is blepharospasm, 
which persists after inflammation of the conjunctiva has 
subsided. Men suffering with this condition come wear- 
ing a shade over one or both eyes. The shade, like the 
crutches, acts as a constant suggestion and keeps up the 
disability. I have cured many eases by taking the shade 
away and isolating the patient in a darkened room, at the 
same time assuring the patient that the cause had gone 
and that the spasm would certainly cease. 

The discomfort and pain produced by the irritation of 
the skin and mucous membrane causes insomnia and 
anxiety, which together with all the stress of active ser- 
vice tends to nervous exhaustion. So that a number of 



260 WAR NEUROSES AND SHELL SHOCK 

officers and men after exposure to attacks by gas shells 
are sent home suffering with neurasthenia. 

The enemy frequently mixes up gas shells with shells 
containing high explosives, and a great danger arises 
thereby, for the air in houses, streets, trenches and dug- 
outs may be saturated with irritant or poisonous gas ; 
and the soldiers may be blown up by high-explosive 
shells, rendered unconscious, and partially buried beneath 
the debris, earth or sand, and therefore perforce exposed 
to drift gas (Phosgene) or the irritant Mustard Gas for 
some time before he can be rescued. This is enough to 
excite fear in the stoutest heart, and the terrible expe- 
rience that a man may go through under such circum- 
stances sinks deep into his mind, and produces a condition 
of hysteria or neurasthenia which necessitates his being 
invalided home suffering with one or a combination of 
both of these war neuroses. The cause is emotional 
rather than commotional, and the personality is the im- 
portant determining factor of the severity and duration 
of the nervous symptoms. 

Neurasthenia and Active Service 

By the new Army Council Instruction No. 712 of 1918, 
no officer invalided home from overseas and admitted to 
a neurological hospital, suffering with shell shock, neuras- 
thenia or functional disorder, can again be sent overseas 
for duty for at least six months after his discharge from 
the special hospital. " In no case will an officer be placed 
in Category A, B, D." 

If the term neurasthenia were always limited to the 
definition of Dejerine, this new instruction would be very 
valuable; unfortunately the term is applied loosely, and 
war-weary officers feel it a hardship to be placed in a hospital 
for neurasthenics and hysterics, and subsequently sent to 
Home Service when they feel that a month' s special leave 
would make them fit for active service. And I have found it 
sometimes necessary to change the diagnosis to Debility. 



NEURASTHENIA AND ACTIVE SERVICE 261 

By an Army Council Instruction No. 517 of 1918, " Offi- 
cers' University and Technical Classes," " Arrangements 
are now made for officers : (1) In Reserve Units, (2) in 
Command Depots, (3) in Hospitals, to be attached to 
certain Centres of University, Technical, Business, or 
workshop training, provided they are reported by a medical 
board as unlikely to be fit for general service. Category A, 
in less than six months, but fit to attend an Officers' Uni- 
versity and Technical Class, which for this purpose is 
considered equivalent to Category C 2." Officers who 
desire to take advantage of these arrangements can obtain 
direct from the Controllers Appointments Department, 
Ministry of Labour, Gresham House, Old Broad Street, 
E.C.2, a pamphlet showing the regulations under which 
they may be attached to a centre of instruction, and 
an application form. This is an excellent provision for 
aiding the recovery of neurasthenia, as it affords interest- 
ing occupation and mental diversion. It tends to allay 
mental introspection and the feeling of depression caused 
by unfitness for service. An additional wise provision 
against financial anxiety is that an officer permitted 
to attend these classes receives full military pay and 
allowances. If he is found fit for general service he will 
be liable to be recalled to military duty. 

" Soldiers 

" (9) All soldiers suffering from neurasthenia, shell shock 
or other functional nervous disorders, when no longer in 
need of hospital treatment will be examined by a Neuro- 
logical Medical Board at the Special Neurological Hospital, 
which will decide whether or not the soldier is fit for some 
form of military service. 

" (10) If considered fit for further military service, the 
soldier will be discharged from hospital to furlough under 
III Employments and the A.F.W. 3016, and the soldier's 
medical history sheet (A.F.B. 178) will be clearly endorsed 
in red ink." 

" Neurasthenia — not to be sent overseas until reboarded 



262 WAR NEUROSES AND SHELL SHOCK 

by Neurological Medical Board under A.C.I. 712 of 
1916." 

If kept in the army he is sent to various employments 
for which he may be deemed suitable. He can only be 
employed on home service, but after the expiration of six 
months and after re-examination by the Neurological 
Board at one of the special neurological hospitals, it will 
be decided : — 

(a) Whether the soldier is fit to be sent overseas, and, 
if so, in what category ; 

(6) Whether he should remain in his present category 
for home service only, and, if so, for what period ; 

(c) Whether he should be discharged from the service. 

The authorities now recognise that the great majority 
of cases of " War Neuroses " proceeding from overseas 
are either unfit for any military service or not fit for 
service overseas for at least six months. 

Experience has shown that in a conscript army a large 
number of men are necessarily recruited who are con- 
stitutionally unfit, and who will never repay the outlay 
made on them. It is useless trying to make these men 
soldiers, and it would be in the interest of the State to 
discharge them from the army as soon as they have been 
proved to be worthless material. When it is considered 
that a man even at the end of six months is not likely to 
have recovered sufficiently to be sent overseas, and his 
occupation prior to joining the army is one of national 
importance, such as farm-labourer, miner, skilled artisan, 
etc., it is better, in my judgment, to board him out of the 
service rather than send him to employment at his depot. 
There is another reason, and that is the tonic influence 
of leaving off the uniform and returning to civil life. 

Chronic Functional Paralyses and Contractures 

in Pensioners 
Chronic functional paralyses and contractures are due 
in great measure to lack of experience of medical officers 



FUNCTIONAL PARALYSES 263 

in the differential diagnosis of functional and organic 
disease, resulting in neglect of early treatment. Conse- 
quently, large numbers of soldiers have been boarded out 
of the army and have received pensions for curable dis- 
abilities. ^ The receipt of a pension does not tend to 
recovery in a number of these cases. No case should be 
discharged from the army with a curable disability. The 
Pensions Board at Putney, to whom cases are referred 
before discharge, has come to a similar conclusion, and has 
recently sent to me many soldiers to report upon (a) the 
disability, (b) treatment. Many of these cases have been 
admitted to hospital, and most of them have either been 
cured or greatly benefited. 

The cases fall into three groups. 

1. The neglected functional case. 

(a) The type of contracture with deformity, e.g. 

talipes equino-varus {vide Fig. 42). 

(b) The flaccid type with disuse muscular atrophy, 

e. g. brachial monoplegia. 

2. Functional paralysis, flaccid type and contracture 

type following G.S.W., with or without fracture of bones 

and cicatrices, but the nerves of the limb not injured 

(Figs. 67-69). 

^ Colonel Salmon, Senior Consultant in Neuro-Psychiatry for the 
American Army, was sent to England in 1917 to investigate and report 
upon the " Care and Treatment of Mental Diseases in War Neuroses 
(' Shell Shock ') in the British Army," and in this Report, published in 
Mental Hygiene (Vol. I, No. 4), he makes the following statement : " No 
medico-military problems of the war are more striking than those growing 
out of the extraordinary incidence of mental and functional nervous 
diseases (' Shell Shock ')." Together these disorders are responsible for 
not less than one-seventh of all discharges for disability from the British 
Army, or one-third if discharges for wounds are excluded. A medical 
service newly confronted like ours with the task of caring for the sick and 
wounded of a large army cannot ignore such important causes of iuvahd- 
ism." He also adds : " Improper management may add to the primary 
neurological disability — which is largely beyond our power of preventing — 
secondary effects, which go even further in producing nervous invahdism. 
Long- continued treatment in general hospitals, confusion of the neurosis 
present with the organic nervous diseases, and unintelligent management, 
all tend to produce the chronic * shell shock ' cases which are so famiUar 
in the special hospitals for these disorders." 



264 



WAR NEUROSES AND SHELL SHOCK 




Figs. 67, 68, 69.— Pte. C, 
5th Wilts. Penetrating bul- 
let wound of arm, April 1916. 
Bullet removed a month after. 
Funct^ional condition super- 
vened; hand clenched and 
unable to use it, no loss of 
sensation. Sent to various 
hospitals and convalescent 
camps till cured by suggestion 
in three weeks at the Mauds- 
ley Hospital, July 1918. Now 
working in the carpenter's 
shop. 

A. Usual position of clen- 

ched fingers. 

B. Attempt to move fingers. 
C After cure by suggestion. 




FUNCTIONAL PARALYSES 



265 



Many of these cases gave a 
history of prolonged immo- 
bility by the use of a splint, 
with consequent arthritic and 
muscular changes ; in advanced 
cases there are vaso-motor, 
thermal and secretory changes 
in addition {vide Figs, 35, 36, 
38). The pain of the wound 
or cicatrix may cause persis- 
tent reflex immobilisation, 
with secondary muscular and 
arthritic changes, suggesting 
to the inexperienced a perma- 
nent disability. 

There are forms of chronic 
functional contracture and 
paralysis which are extremely 
difficult to cure. They are 
long-standing cases following 
wounds. The scars of the 
wounds seem to act as a con- 
stant source of suggestion of 
the permanence of the dis- 
ability. In cases where the 
disability causes no serious 
discomfort, and ensures much 
sympathy, alight job, and the 
continuance of a pension, the 
idea of a permanent disability 
becomes installed and firmly 
fixed in the mind, so that cura- 
tive contra- suggestion often 
finds the individual irrespon- 
sive and difficult to treat. 

3. Organic paralysis due to 




Fig. 70. — Injury of median 
nerve. Hear of incision for opera- 
tion of suturing. Regeneration 
taking place as shown by the fact 
that pressure along the course of 
the nerve below the widest part 
of the scar gives tingling in the 
index and middle fingers. The 
position of the hand resembles a 
functional "Main Accoucheur," 
except that the little finger is 
inflexed on to the hypothenar 
eminence; but the cause of this 
condition is not functional, it is 
due to a cicatrix at the root of 
the thumb, and another along the 
palmar surface of the little finger. 
These cicatrices were caused by 
two incisions necessitated by sep- 
tic inflammation and suppuration 
of the palm, a tube having been 
placed through from one incision 
to the other. 



266 WAR NEUROSES AND SHELL SHOCK 

G.S. Wounds injuring peripheral nerves (Figs. 70, 71), the 
plexuses, or the spinal roots, with consequent motor paralysis, 
muscular atrophy and absence of electrical reactions or re- 
action of degeneration have been the cause of the disability 
and deformity. Usually there is associated with the paralysis 
of groups of muscles a corresponding area of anaesthesia 
{vide Table, p. 176). A large superadded functional 
paralysis sometimes occurs in cases of limited organic 




Fia. 71. — A case of accoucheur liand uikut cnioroforru anaesthesia. 
This case resisted treatment by physio -psychotherapy, and liad to be dis- 
charged. A comparison of the right and left hand shows that the deformity 
still persisted, although he was under deep narcosis. The case was one of 
injury of the median nerve (Fig. 46), and tends to show that myogenic 
changes had taken place. 

disability. In some of the cases the injured nerve had 
been sutured and regeneration had taken place, but 
muscular and arthritic changes had been allowed to occur 
from neglect of after-treatment. 

My experience leads me to the conclusion that great 
numbers of soldiers have remained in hospitals, connnand 
depots and convalescent camps many months, and not 
an inconsiderable number for over a year, suffering with 
disabilities which could have been cured by a skilful 
neurologist in a few minutes, a few hours, a few days, or 



TREATMENT OF WAR NEUROSES 267 

a few weeks, and thereby an enormous saving of money 
and man-power might have been effected. 

The General Treatment of War Psycho-neuroses 

The essential before commencing treatment is a care- 
ful examination of the patient, and much time will be 
eventually saved by thoroughly going into the previous 
history of the patient in order to ascertain how much of 
his disability is due to pre-war acquired conditions, and how 
much to his inborn constitutional make-up as afforded by 
his family history — what he was born with, as well as what 
happened after birth; otherwise pre-war conditions may 
be confounded with conditions due to service, and the 
distiiiction of " in and by military service " not accurately 
gauged. Moreover, the information thus obtained is most 
valuable as regards prognosis in respect to whether he is 
unfit for military service, and should be discharged as 
permanently unfit. This information will also help in 
deciding which category the patient should be put in when 
discharged from the hospital. Again, it is of importance in 
deciding the amount of gratuity or pension which should 
be awarded in each case. 

After taking the family and personal history, a careful 
examination of the patient should be made; not merely 
a physical examination, but a mental examination. This 
should be undertaken apart from his comrades, and every 
effort should be made to obtain the patient's confidence. 
He should be asked to tell you fully his troubles, if he has 
any, and particularly so if an anxious and worried expression 
suggests a mental confiict. Often the examining physician 
will find that the man is haunted by the terrible experiences 
he has gone through and by the sights he has seen, which 
trouble him by day and terrify him in dreams by night. 
The assurance that he will not be sent back will often do 
much to relieve his anxiety. Sometimes it will be found 
that he is worrying about family, domestic and financial 
troubles or in fear that he will never recover. When he 



268 WAR NEUROSES AND SHELL SHOCK 

feels that he has found a friend in the doctor, who is not in 
a hurry, but will listen to him, he will have faith in him; 
and in these functional war neuroses due to psychic trauma 
Charcot's dictum is especially applicable, " C'est la foi qui 
sauve ou qui guerit." It may take several sittings before 
the mental struggle which is at the foundation of his anxiety- 
neurosis is revealed to the physician. A sympathetic 
hearing of his troubles should be followed by wise counsel, 
and the endeavour to strengthen his will-power by en- 
couragement and hope for the future. This is the psycho- 
analysis which every humane physician who tries to get 
his patient to regard him as his friend and confessor will 
practise, if he is not too busy. 

A careful physical examination is next made. The 
patient has now confidence that his case is being thoroughly 
gone into; and having faith in the judgment of the 
physician he is open to suggestion. For he will reason 
thus : This doctor has not neglected me; he has not said, 
"Case of no interest," "Functional," "Shell Shock," 
" Neurasthenia," " Hysteria," which sometimes happens 
when such patients are mixed up in hospital with cases 
of wounds or of organic disease. The feeling, often 
imaginary, of being neglected and of being despised by 
comrades is not likely to induce faith, and thereby recovery. 

In the main there are three types of cases which require 
treatment: (1) hysteria; (2) neurasthenia; (3) a com- 
bination of hysteria and neurasthenia. 

The hysterical symptoms can be cured by physio- 
psychotherapy in several ways, and a detailed description 
of the methods will be given later. The neurasthenic 
symptoms can be greatly aided by suggestion, especially 
the anxiety states and phobias. 

Treatment of Shell Shock and Neurasthenia 

I am informed by medical officers at the clearing stations 
that there is an increase of pressure of cerebro-spinal 



TREATMENT OF SHELL SHOCK 269 

fluid in true shell-shock cases, and that sometimes even 
it is blood-stained or contains albumin; also that relief 
of symptoms occurs by withdrawing fluid by lumbar 
puncture. 

The treatment of the neurasthenic symptoms of shell-shock 
varies to some extent in different individuals, according 
to their nature, but there are some symptoms which are 
seldom absent in all true cases, viz. tremor, fatigue, dizzi- 
ness, headache, insomnia and terrifying dreams. I have 
found the continuous warm bath of great value in the 
treatment of these cases when they come over from France. 
The water in the baths is kept continuously at the temper- 
ature of the blood by a special mechanism of heat regula- 
tion; the patients are kept in the bath for a quarter to 
three-quarters of an hour, or even longer. The effect is most 
soothing to the nervous system, and one can understand how 
it is so from the fact that the whole of the sensory nerves 
of the skin are acted upon by the warmth ; the tired muscles 
are relaxed, and the blood is withdrawn from the internal 
organs, including the brain, to the skin. These baths are 
extremely useful in cases of maniacal excitement. Often 
the bath, with a drink of warm milk at bed-time, suffices 
without hypnotics to produce sleep. But if hypnotics 
have to be given, the quantity required is less when com- 
bined with the baths. The hypnotics I recommend are 
trional, gr. x-gr. xv, preceded by mist, paraldehyde gij, 
or this alone. Pot. brom. or chloral, of each 15 gr., and 
either tinct. opii TT|^ xv, or tinct. cannat. ind. n\ x. 
Dial two 1\ gr. tablets. In maniacal excitement hyoscin 
ill \hi ~ tV gr. doses hypodermically. It is better to avoid 
drugs if possible, but sleep is indispensable. The next thing 
is to attend to the general bodily condition by nourishing, 
digestible, and easily assimilated food; and lastly, very 
important is attention to the primae viae, by which auto- 
intoxication and cerebral congestion can be relieved. A 
dose of calomel at night and saline in the morning is the 



270 WAR NEUROSES AND SHELL SHOCK 

usual practice. The severe headache from which these 
patients suffer, requires relief by an ice-bag to the head, 
aspirin, phenacetin, and other drugs which relieve neuralgic 
pains. 

After the patient has recovered from the more serious 
condition of shock, and the mind is becoming more alert 
and interested in its surroundings, we have to consider how 
best to allay the symptoms which nearly all suffer from, 
viz. headaches, dizziness, tremors, feeble circulation, and 
exhaustion readily brought on by mental or bodily effort. 
As a sedative and nerve tonic I usually prescribe dilute 
hydrobromic acid, quinine, and strychnine. I have found 
pituitrin useful in cases of low blood-pressure. When the 
symptoms point to hysteria, bromide and ammoniatcd 
tincture of valerian are prescribed. If the patient is 
sufTiciently well to sit up, it is better that he should do so, 
at first for a few hours a day, if possible in the open air. 
To severe cases, the noise of gramophones, pianos, the click 
of billiard balls, and even musical instruments, excite and 
aggravate symptoms; quiet repose in single rooms, such 
as we have at the Maudsley Hospital, is undoubtedly a 
most important and necessary mode of treatment in the 
early stages of severe cases. 

At the same time these patients should not be left alone ; 
quiet and unstimulating diversion of mind should be en- 
couraged to avoid introspection and dwelling upon the 
terrible experiences they have gone through. These men 
are often too tired or unable to read on account of inability 
to concentrate attention and fatigue of the muscle of 
accommodation, and the mind may be diverted by simple 
games, knitting or wool work, bead work, basket work, and 
net-making. 

Mental Hygiene in Later Stages 

As soon as they are better, patients are encouraged to 
play billiards, cards, and other games, in the winter time 



TREATMENT OF SHELL SHOCK 271 

especiA,lly; also there are frequent concerts and popular 
lectures, all of which serve to divert the mind and produce 
an atmosphere of cure, which is very essential. Soldiers 
will put up with a good deal provided they have good and 
abundant food, and it is essential for recovery that there 
should be no grousing. 

Grumbling and grousing are contagious, and it is always 
well to get rid of a soldier from a ward if he is exciting 
discontent in the others. Discipline is very essential; 
laxity of discipline, over-sympathy and attention by kind, 
well-meaning ladies giving social tea-parties, drives, joy- 
rides, with the frequent exclamation of " poor dear," has 
done much to perpetuate functional neuroses in our soldiers. 
The too-liberal gifts of cigarettes has produced a cigarette 
habit in officers and men, which is highly detrimental in 
these cases of war neurosis, especially in cases of irritable 
dilated heart, and in other forms of cardiac neurasthenia. 

Again, in many cases of functional paralysis the idea 
of a permanent disability requiring pension for the rest of 
a man's life may become a fixed idea, owing to wrong 
diagnosis, over-sympathy, and misdirected treatment. In 
many of these cases (as I have found) what is required 
is merely strong suggestion to the patient that there is 
nothing the matter with him except the idea that he is 
paralysed, which has become installed and firmly fixed in 
his mind by prolonged bed, daily massage and electricity, 
suggesting to him that there is an organic disease causing 
his complaint. I have seen many cases of inability to stand 
or walk, who yet could move their legs in bed, and by 
the tests I have described exhibited conditions definitely 
pointing to functional paralysis and not to organic disease. 
Being thus sure of my ground, I have told the patient to 
get up, and I would support him and see that he did not 
fall. I have then engaged his attention by asking him 
questions about himself and his former life while gradually 
relaxing my hold,until he was standing without any support. 



272 WAR NEUROSES AND SHELL SHOCK 

After a little while, I say to him : " Now, you did not know 
that you have been standing about five minutes without 
any support." I have often succeeded in making such a 
patient walk. Men have come who have been using 
crutches for a long time, and I have told the sister to take 
the crutches and put them in the museum, for this patient 
did not want them. 




Fig. 72. 



Treatment of Hysterical Paralyses, Contracture, 
Mutism and Other Disabilities 

I have found it useful to explain to an officer or an 
intelligent soldier the fact that in bilateral associated 
movements, such as in swimming, or raising the arms above 
the head to seize a horizontal bar, one half of the brain will 
initiate the movement in both upper limbs, and that, inas- 
much as the one arm is paralysed because the opposite 
half of the brain has lost voluntary power over it, that these 
associated movements will revive the function {vide Figs. 35, 
36). Probably he will be interested and his attention will 
be directed towards the process of re-education. I then 



TREATMENT OF HYSTERICAL CONTRACTURE 273 





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274 WAR NEUROSES AND SHELL SHOCK 

perform a number of associated movements of the two 
arms together, the healthy one and the paralysed ; myself 
assisting the immobile arm, telling the patient to help 
me by thinking of the same movement. After a little while 
he may be doing the main part of the movement himself. 

When in addition to paralysis there is a contracture and 
deformity, e. g., in long-standing talipes equino-varus, I 
have found the following procedure effective. Continuous 
passive movements (kept up for hours on successive days) 
to overcome the deformity by fatiguing the group of muscles 
which are in a state of permanent contracture. This 
procedure no doubt acts by suggestion, and mechanically 
by fatiguing the group of muscles that are the cause of the 
deformity. 

It may be necessary in protracted, long-standing cases 
of contracture and paralysis to give an anassthetic to 
break down the adhesions in the joints. For a few days 
after the parts may be swollen and painful. Massage and 
passive movements, telling the patient at the same time 
to think and will the movements, are very useful in restor- 
ing the nutrition of the muscles and voluntary power. 
Faradism of the muscles, showing the patient that they 
contract and explaining to him that this is a certain proof 
that the limb is not paralysed, is a very useful form of 
suggestion. Another useful method of suggestion applic- 
able especially to flaccid paralysis of the arms is to tell the 
patient to shut his eyes and reproduce all the movements 
in the healthy sound limb that I make in the paralysed 
limb. If he does this I feel confident of a good result. 
I tell the patient that I have obtained definite proof that 
his brain is in connection with his paralysed limb, and that 
all he has to do is to will the movements which I am 
making and he will soon feel his muscles contracting. 

When there is acrocyanosis and hypothermia I explain 
to the patient that this is caused by the immobility, and 
that just as the hand which is benumbed by cold becomes 



THE ATMOSPHERE OF CURE 275 

useless, so upon restoring the circulation by friction and 
warmth the feeling and usefulness of the hand returns. 
I therefore tell him that we shall restore the warmth 
and circulation in the hand by radiant heat, by massage 
with the vibrator and passive movements. 

It has occurred to me that the vaso-motor paralysis 
that causes the acrocyanosis in a part psychogenically 
immobilised for a long time can be explained physiologic- 
ally by a lapse in the habitual automatic association of 
the cortical sensori-motor centres, presiding over bodily 
structures, with corresponding autonomic centres that 
control and regulate their blood supply in accordance with 
their functional activity. When the muscles are for a 
long time inactive the blood supply is only sufficient to 
provide for their nutrition. A vicious circle tends to be 
established, for the muscles being inactive and cold, kinaes- 
thetic and other sensory stimuli from the superficial struc- 
tures no longer excite the brain. The sensori-motor centres 
in the brain, like the hand, are benumbed. 



The Atmosphere of Cure 

Nothing excites faith so much as seeing the benefit of 
treatment. A special treatment room is set apart in the 
Pathological Department of the Maudsley Hospital, and 
the large adjoining library is used as a waiting-room. Here 
are gathered not only numbers of patients from the 
Maudsley Hospital, but numbers of others sent from other 
hospitals for treatment. A soldier deaf, mute or paralysed 
who comes out of this room, as they almost invariably do, 
hearing, talking, and walking makes a deep impression on 
the minds of comrades waiting their turn to be treated for 
similar functional disabilities. 

I reproduce here a notice fixed on the door of the special 
treatment room; it was spontaneously designed, executed 
and placed there by a grateful sergeant who had been 



WAR NEUROSES AND SHELL SHOCK 

cured of a functional paralysis which had supervened on 
the basis of an organic spastic paralysis (Fig. 75). 

Having thus by one means and another obtained the 
faith of the patient, it/loes not matter much which method 
of counter-suggestion is employed. As a rule the physio- 
psychic is the most certain and expeditious, but selection 
of method is the best procedure to adopt, for I have found 
one method succeed where another has failed. 




ROOM OF RECOVERY 



j^BTxion doubt ^ Tear 
^11 )£'^'^)c}t tnttr bat 




Fig. 75. — The room of recovery. 

The paralysis or contracture having been overcome by 
counter-suggestion, the next thing is re-education. 

1. Hypnotism. — I have seldom practised this method 
of treatment, and it has for the most part been given up, 
because of its uncertainty, and because of the relatively 
large number of relapses reported ; not to mention the bad 
after-effects it has on some patients. Sometimes light 
hypnosis will enable the patient to bridge over a slight or 
moderate amnesia; some physicians also prefer to treat 
insomnia by light hypnosis rather than give potent narcotics, 
and in skilled hands it has met with success. 

2. Discipline. — Military discipline is essential for the 



THE ATMOSPHERE OF CURE 277 

satisfactory treatment of cases of functional neurosis. 
All patients should be made to salute officers and stand to 
attention when they enter the wards. Laxity in discipline 
and excuses for bad conduct should not be tolerated. In 
my judgment military discipline is very essential for the 
treatment of hysteria. No case should be discharged from 
the army with a curable functional nervous disability. He 
should be told that he will remain in the hospital until he is 
either fit to return to his command depot, placed . in a 
category, or discharged. If discharge is recommended I 
require that some ability for occupation should be shown, 
and the patient is asked to obtain a letter from his former 
employer stating that he is willing to take him back and to 
give him light employment. 

A man discharged from the army suffering with mutism 
or hysterical paralysis, and receiving a pension is likely to 
remain mute or paralysed. It is a mistake to grant pensions 
or gratuities to purely hysterical cases, as it tends to perpetu- 
ate the functional disability. Hysteria is often confused 
with neurasthenia ; it is easy to cure the hysteria, biit the 
neurasthenic symptoms persist, and such cases require 
longer treatment. 

3. Simple Re-education. — This is a relatively slow and 
tedious process which is almost impractical now, when 
there are so many cases to treat and so few physicians 
competent to treat them. Here, as in every method of 
treatment by suggestion, the patient is just told in simple 
language about his disability and its causes and what to 
do for their relief; and he is given some simple examples 
of similar conditions in everyday life. He is then shown 
why he cannot perform some simple movements, articula- 
tion, etc. In the case of functional muscular paralyses, 
passive movements are first made in which the patient 
learns to overcome passive resistance. Later active move- 
ments are attempted, continually showing the patient 
where and why he fails to perform these correctly. He soon 



278 WAR NEUROSES AND SHELL SHOCK 



/ 



begins to improve, and continued practice under strict 

supervision completes the cure after 

Na long or short period. With this 
method one must be careful not to 
produce too much fatigue in the 
patient, as poor results, possibly 
due to accumulation of fatigue 
poisons, are probably produced in 
a certain percentage of cases where 
intensive exercising is contra-indi- 
cated, e. g., in cases which have 
been bedridden for a long period, 
or in the emaciated. 

4. Re-education reinforced by 
Electricity. — By this method cures 
are produced very rapidly in prac- 
tically every case of hysterical 
(pithiatic) disorder. The secret of 

Vthe success with this method is just 
to proceed as in the simple re- 
educative method ; ascertaining just 
what the patient can do, and then 
explaining exactly the reason for 
applying the faradic electricity. 
Then the patient is put at his ease 
and told that he will not suffer 
pain during the treatment. A very 
mild faradic current is first applied 
to the affected parts; at first not 
strong enough to produce contrac- 
tion of the paralysed muscles, later 
becoming stronger and stronger 
until there is a lively contraction in 
the affected group with each make 
and break of the current. It is well during the treatment 
to produce contraction of paralysed muscle groups, or to 




RE-EDUCATION BY EXERCISES 



279 



faradise the an- 
tagonists of 
contractured 
muscles suffici- 
ently to over- 
come the dis- 
ability, the 
patient during 
the gradual 
release of the 
current being en- 
couraged to ex- 
ercise his own 
mental control 
of the same. 

5. Re-educ a- 
tion by Exercises. 
— ^The different 
abnormal gaits 
depend for cure 
more upon re- 
education than 
upon other forms 
of suggestion, 
the physician' s sympa- 
thetic but firm encourage- 
ment, and corrective in 
struction to the patient r 
being essential for success. '• 
A great deal of patience 
and endurance of both in- 
structor and instructed are 
required in the treatment 
of these disabilities. The 
patient, having^^been shown 
that all his muscles contract when stimulated, is told 




Lcourage- ^^^^^^^A ^H^^^^^^ 
in- • ^^H^^^^^ ^^^^^^^^ 



ir 



Fia. 77. 



280 WAR NEUROSES AND SHELL SHOCK 

to stand to attention. As in many of these patients, 
the sole of the foot is shuffled along the ground; he is 
toM to' do the goose-step, bending the knee of the advanc- 
ing foot fully, then extending it and pointing the toe 
before the sole of the foot is placed firmly on the ground. 
He is kept at this until he does it well. He is then taken 
to footprints of a normal person (painted on the floor) and 
instructed to walk, seeing that his feet cover each footprint. 
He is then required to perform the more difficult exercise 
of covering the footprints by crossing the advancing leg 
over the resting {vide Figs. 76, 77). The disability of gait 
and station, caused by a coarse hysterical tremor or shaking, 
may be cured by the same method of suggestion and re- 
education. After the patient has been cured he is required 
to attend daily the class for convalescent cases. 

Exercises for Convalescent Gases of War Neurosis 

1. Breathing through the nose, filling the chest and 
slowly but steadily expelling the air through the nose. 
The same, accompanied by raising the arms above the 
head with deep inspiration, and bringing them down to 
the side in expiration. 

2. Neck (counting four). 

(1) Chin forward. 

(2) Chin back on chest. 

(3) Chin to the right shoulder. 

(4) Chin to the left. 

3. Shoulder (counting three). 

(1) Lifting right shoulder and letting it drop by 

its own weight. 

(2) Lifting left shoulder and letting it drop by its 

own weight. 
• (8) Lifting both shoulders and letting them drop 
by their own weight. 



TREATMENT OF SENSORY CONDITIONS 281 

4. Arms (counting three). 

(1) Arms pushed forward, hands closed. 

(2) Arms back as far as possible and in line with 

shoulders. 

(3) Arms bent, hands open and touching shoulders. 

5. Back (counting four). Legs apart and kept stiff. 

(1) Bending spine forward as far as possible, arms 

extended and reaching down as far as 
possible. 

(2) Bending spine back slightly. 

(3) Bending spine to the right. 

(4) Bending spine to the left. 

6. Legs. 

(1) Hopping on right leg. 

(2) Hopping on the left. 

(3) Hopping on both. 

7. Stationary running. 

These exercises, when properly performed, show the 
mobility of all the joints of the body and any disability 
is readily detected. 

Each exercise is repeated twenty times. 

Treatment of Hysterical Sensory Conditions 

In cases of anaesthesia a faradic brush or roller with 
gradually increasing current will (as a rule) effectively 
cure sensory disabilities in the space of a few minutes. 
A useful method of restoring sensibility in a part insensitive 
to pricking is to connect the needle with the movable 
electrode employed in faradisation. 

He does not know when the needle will give the electric 
shock, and it generally awakens the dormant sensibility, 
so that the feeling of a prick without any current is soon 
restored. 



282 WAR NEUROSES AND SHELL SHOCK 

Hysterical blindness is usually not difficult to cure when 
the patient has not become disheartened by failures through 
being handled incompetently. The patient being confident 
'that he will get well, and being constantly reassured by 
the physician, has then a mild faradic current applied to 
the supra or infra orbital notch. The current is gradually 
increased until it becomes slightly painful ; meanwhile, he 
is given the suggestion that he will gradually see shadows, 
then the outlines of objects placed before him, at first 
moving slowly and gradually more rapidly. 

Deafness is treated in a similar way with the application 
of the current to the mastoid region or the external auditory 
meatus. The use of the stethoscope to the patient's ears 
as a means of suggestion, shouting in the ear while the 
current is passing, or the application of tuning-forks of 
different vibrations may be tried as a means of restoring 
the funct'on. 

Physio-psychotherapy in the Treatment of 
Mutism 

The method employed is as follows : the patient, after 
a careful and thorough examination, is assured that he 
will be cured of his disability. If it is a case of mutism 
or aphonia, he is asked to produce sounds, to cough, to 
whistle, to say the vowel sounds, which he will probably 
not be able to do. The voice may return by suggestion 
only. But a more rapid method is to reinforce suggestion 
by the application of the faradic current to the neck by 
means of a roller electrode or brush. The current is in- 
creased in strength and very often the patient immediately 
recovers his voice and speaks. If he does not speak, he 
is again faradised with the roller or brush electrode and 
made to say. Ah, A, Ee, Oh, Oo. 

Most mutes cannot speak because they cannot phonate ; 
they cannot phonate for two reasons : (1) because the vocal 
cords remain motionless, (2) because the mute cannot 
control the breath. The voluntary adduction of the vocal 



TREATMENT OF STAMMERING 283 

cords is inhibited; likewise the voHtion required to 
initiate and control the expiratory blast of air necessary 
to set them vibrating — ^the two essentials in phonation. 
A psychogenic perseveration of an instinctive fear reaction 
operating on the cortical centres presiding over the volun- 
tary control of the breath in phonation causes a dissociation 
of those centres and consequent mutism. A sudden painful 
surprise suffices for an instant to arrest the unconscious 
psychogenic perseveration, and its dissociating influence 
is overcome by a cry, which is the natural instinctive 
reaction to pain ; this gives us the clue to the influence of 
faradism and its mode of application in the cure of mutism. 
We have now to keep up this reassociation of the cortical 
centres of phonation and add to it (if still absent) the pro- 
duction of articulate sounds. We make the patient say 
the days of the week, the months of the year, and to count 
up to twenty. Records before and after treatment are 
frequently taken on the dictaphone, and mutes are 
allowed to hear these records before treatment to encourage 
them. 

By such treatment hysterical mutes have been invariably 
cured at one sitting. 

Treatment of Stammering and Stuttering 

Stammerers, stutterers, and patients who repeat syllables 
or words in a jerky and tremulous manner may be similarly 
treated, but as a rule, especially if they have stammered 
in pre-war times (as many have done), careful and daily 
repeated exercises, first consisting of breathing lessons, are 
required. Patience is necessary. They are told to close 
their mouth and take a full breath through the nostrils, 
and then blow out in a steady blast through the hands 
held up to the mouth like a trumpet. As soon as they 
blow in a steady stream they are made to produce the vowel 
sounds in the middle of the register, great care being taken 
to see that the patient produces these sounds without 
tremor or jerkiness. It is well known that the person 



284 WAR NEUROSES AND SHELL SHOCK 

who knows how to control the breath has acquired the 
fundamental principle in the art of singing. If the patient 
is intelligent the action of the diaphragm can be explained 
to him. He may be told that the chest contains the lungs, 
which by their elasticity expand mainly by the descent 
of the diaphragm when air is breathed in, and that this 
air can be forced out in a steady flow through the windpipe 
by the diaphragm being made to act like a piston in the 
barrel of a syringe. The lungs then constitute the bellows 
of the vocal organ in speech and song. But the air as it 
is forced out in a steady stream through the chink of the 
glottis sets the vocal cords vibrating, and this produces 
sound. The pitch of the sound depends upon the rapidity 
of vibration of the vocal cords, and this is regulated by 
muscles that stretch and approximate them. The loud- 
ness depends upon the force with which the air is driven 
against the vocal cords, and the evenness of tone depends 
upon the steadiness with which the air is expelled from the 
lungs. Consequently, both the loudness and the steadiness 
are regulated by a force which presses upon the diaphragm 
and forces it up so that the air is expelled from the lungs. 
Now, this control of the breath is effected by the will acting 
upon the abdominal muscles in such a way as to act like the 
force which blows the bellows of an organ. Re-education, 
then, consists firstly in the acquirement by practice of the 
control of all the muscles which expel the air from the lungs. 
Many of these speech defects are caused also by a lack 
of correlation between this control of the breath by the bel- 
lows and the modification of the sound by the articulatory 
mechanism of the tongue, the lips, the jaw, the teeth and 
the palate in the production of the consonants. A tremor 
of speech in cases of war neurosis is often due to a tremor of 
the lips, and this shows itself especially in the lip explosive 
consonants M, B, P. Subjoined is a useful tabl^ taken 
from Wyllie for testing the progress of. re-education in 
stammerers and stutterers, etc. Fear and apprehension 



TREATMENT OF STAMMERING 



285 



inhibit the normal automatic correspondence of the two 
mechanisms, the control of the breath and the modifica- 
tion of the sounds by the articulator mechanisms. For 
re-education of the stammerer and stutterer, I make the 
patient utter the first simple vowel sound and then place 
the consonant in front, lastly the rest of the word. Thus 
in Peter : e-Pe-ter, Peter; Brown: Bur-own, Brown. The 
great secret of success is patience on the part of the 
instructor and perseverance on the part of the patient. 



PHYSIOLOGICAL ALPHABET (WYLLIE) 



1 


1 e 


a o 


u 


Vowels 


Eels Ail 


Amid Ocean 


Ooze 




Initial Y closely related to i, yes. 






„ w „ 


., u, weary. 






Voiceless oral 


Voiced oral 


Voiced nasal 




consonants. 


consonants. 


resonants. 


Labials 


Peter 


Brown 


Made 


let stop position 


(W)hite 


Wax 




Labio- Dentals 


Fine 


Villages 




Linguo- Dentals 


Thinkest 


Thou 






So 


Zealot 
zh 




Anterior 


She 


Leisurely 




Linguo-Palaials 


Took 


Down 


Nine 


2nd stop position 


(L) 


Large 
Roses 




Posterior 


K 


G 


Ng 


Linguo -Palatals 


Can 


Gilbert 


Bringr 


3rd stop position 


Loc/i Hourn 


Youths ? 






Fricatives. 


Fricatives. 


Resonants. 


3 


Far 2 


We 4 


My Nephew 




Shores 


Visit 






Seem 


Thee 






Thinly 


Zulus 






Hazy' 


Like 

Ramblers 

Yearly 





6 Explosives. Explosives. 

Two Poor Comrades 5 Best Gold Dust 
Note. — Stammering. NomeraLs, give order of difficulty, 

1. Mother make more mustard. No, no ! not now. >^ 

2. Billy Button bought a buttered biscuit. 

3. Davy Doldrum dreamt he drove a dragon. 

4. Gaffer Gilpin got goose and gander. 

5. Peter Piper picked a peck of pepper. 
C. Tiptoe Tommy turned a Turk for twopence. 
7. Kimbo Kerable kicked his kinsman's kettle. 



Test 
Exercises. 



286 WAR NEUROSES AND SHELL SHOCK 

Physio-psychotherapy in the Treatment of 
Paralysis and Analgesia 

If the patient suffers with paralysis the muscles are made 
to contract by applying the electrode to the points necessary 
for exciting the appropriate nerves. He is then told to 
look and see that the muscles all act in response to the 
stimulus, and he is assured that it is only his will that 
refuses to act. The brush or the roller is again applied, 
and he is then told to move the paralysed limb ; if he does 
not do so, the current is applied until he does. For example, 
suppose we are dealing with a case of functional paraplegia ; 
after applying the current he is told to raise the limb from 
the couch, to bend and straighten it and successively told 
to perform movements of all the joints in both limbs. 
Having accomplished this, he is then told to stand up to 
attention; should he make any indication of falling, the 
current is applied to the buttocks or some other part of 
the lower extremities. Next he is told to walk, and the 
stimulus is applied, if necessary, to make him do so, and 
finally, if he is not a long-standing case of functional para- 
plegia, he is induced to do the goose-step, and finally he is 
stimulated to run. There is often a functional analgesia 
of the gauntlet or stocking distribution. This may 
generally be easily removed by the following method. 
The patient is pricked with a needle, and if he says he 
does not feel, I then pass the needle through, or connect 
it with the movable electrode in the circuit of the faradic 
current. I prick him again and he will probably feel, 
for the stimulus will be pretty strong. Very soon he will 
feel well the prick of the needle when no current is passing 
through it. Where there is analgesia it is advisable to 
remove this by physio-psychotherapy before treating the 
paralysis. 



PSYCHO-ANALYSIS BY WORD ASSOCIATION 287 

Freud's Theory of the Unconscious in Relation to 
the Treatment of War Psycho-neuroses by 
Psycho-analysis 

The special characteristic of Freud's theory of the uncon- 
scious is an active repression of a painful experience, and 
his doctrine of the part taken by such repressive experience 
in the production of bodily and mental disorder is the 
principal feature of Freud's theory in its relation to the 
psycho-neuroses; for many morbid mental and bodily 
states are, according to Freud, due to a conflict between 
repressed experiences now usually called complexes and 
the general personality or ego of the sufferer. 

Freud, and more especially his followers, have only seen 
the sexual aspect of the theory, and they have regarded 
sexuality as its sole basic principle. But the experience 
gained since the war shows that this position is no longer 
tenable. 

Psycho-analysis claims to uproot the " complex " from 
the subconscious mind and to bring it back into conscious- 
ness, when it can be influenced by persuasion and reason. 

Psycho-analysis by Word Association 

Stimulated by Bleuler, Jung and Riklin examined many 
educated and uneducated persons by giving them a hundred 
stimulus words for association with other words and noting 
the reaction time. That is to say, they take a series of 
one hundred words; each word is read out clearly by the 
examiner, and the patient is asked to call out the word which 
(recalled by association) first comes into his mind ; the time 
intervening between the pronouncement of the word by 
the examiner and the pronouncement of the associated 
word by the patient is measured by a stop-watch recording 
one-fifths of a second. The following formula is employed : — 

Associated 
Stimulus Word. Reaction Time. Reproduction. 
Word. 



288 WAR NEUROSES AND SHELL SHOCK 

The average reaction time is generally 2*4 seconds. 

Before the experiment is begun, the person to be tested 
is instructed to concentrate his attention upon the experi- 
ment and always to call out immediately the first word that 
comes to his mind. The answer as well as the reaction 
time are carefully noted, and after the whole series of one 
hundred stimulus words has been read out, they are again 
repeated and the patient is asked to repeat the original 
answers, which are again noted M'ith the intervening time ; 
and if another word than the first association is reproduced 
it is noted. Whenever there is an impediment to the re- 
action and a prolonged time interval between the calling 
out of the word and the production of the associated word, 
we are in possession of a fact pointing to a possible complex. 

Jung claims that all apparently adventitious mistaken 
delays in reaction time in the association experiment have 
a definite reason ; and that, contrary to the belief of the 
person tested, his answers may betray his inmost thoughts, 
or at any rate afford a clue to them. 

This method may therefore be applied successfully in 
certain cases of neurasthenia suffering with an anxiety- 
neurosis. Officers, and sometimes men, who are reticent 
regarding the mental conflict underlying the neurosis by 
which they are afflicted, are often found quite willing to 
co-operate in what they not infrequently regard as a sort 
of game or mental exercise for treatment which has little 
or no relation to the discovery of the cause of their anxiety. 

But as soon as the examiner has correctly interpreted the 
delay in association, found the complex, and predicted the 
repressed painful experience causing the mental conflict 
underlying the state of anxiety, the patient's faith in the 
method is aroused, and he will be induced to open up and 
talk freely. 

Needless to say, the examiner requires not only to carry 
out the experiment in a judicious and careful manner, but 
also judicially to interpret the findings. " When the causes 



PSYCHO-GALVANIC REACTION 28d 

for the anxiety have been satisfactorily ehcited, the next 
process is to endeavour to rearrange them so that their 
original effect is no longer produced. In practice this 
mainly consists in making clear to the patient the real 
significance of the memories, fears, apprehensions and so 
forth, reducing them to their proper perspective, and 
thereby adjusting the conflicts and internal stresses which 
underlie the symptoms. Much of this may be described 
as common- sense illuminated by a technical knowledge of 
psychology, but the technical knowledge is an absolutely 
indispensable adjunct." — Bernard Hart. 

The Galvano-psychic Method of Investigation 

Veraguth was the first to utilise the galvano-psychic 
method of revealing repressed complexes. The method 
was pursued further by Jung and Petersen. Instead of 
taking the time reaction with a stop-watch the reflecting 
galvanometer was used as the indicator. The procedure 
of Veraguth is followed in the main on patients at the 
Maudsley Hospital. 

The patient is seated in the chair, and when quite mentally 
composed and adapted to his surroundings, a constant 
current of 2-8 volts is passed through him and balanced by 
means of a Wheatstone Bridge with an Ayrton-Mathus 
moving coil galvanometer suitably shunted. Instead of 
the solid electrodes hitherto used, the hands of the patient 
are plunged into two bowls containing warmed 2 per cent, 
saline into which dip zinc electrodes. It has been found 
that by this method alterations of resistance due to move- 
ments on the part of the patient are reduced to a minimum, 
and the total resistance is reduced to about two to three 
thousand ohms. 

The diminution of resistance constituting the psycho- 
galvanic response is recorded when it occurs and noted. 

A series of words is then read out, a definite interval of 

time between each being allowed. The latent time in 
u 



290 WAR NEUROSES AND SHELL SHOCK 

answering is recorded by a stop watch, and it is found 
that there is a rough correspondence between length of 
latent time and the intensity of the psycho-galvanic re- 
sponse. The latter has been found to be much the more 
reliable as an indication of the existence of an emotional 
complex. A semi-automatic word response may often be 
given within normal time limits, and a few seconds later 
the associations aroused by the stimulus word are awakened 
and manifested by a diminution of resistance opposite the 
stimulus word. In the case of words causing an emo- 
tional reaction, there is deflection of the beam of light 
in a certain measure proportional to the emotional effect, 
for the resistance is diminished owing to the increased 
functional activity of the sweat glands and to the vaso- 
motor effects in response to the emotional disturbance. 

The series of words is repeated, and the reaction is again 
noted. Those stimulus words which gave a marked reaction 
are analysed with a view of interpreting an anxiety com- 
plex. The patient's reaction is again observed when the 
complex, believed to underlie his anxiety state, is predicted 
by the examiner. 

Professor Waller has shown the psycho -galvanic method 
to be of value also in determining a state of emotivity of 
a patient who is suffering from neurasthenia following 
shell shock. Thus a loud noise produced near the patient 
causes a marked reaction; likewise the menace of a burn 
in a man who is in an emotive state whether constitutional 
or acquired. 

This method in the hands of a skilled operator opens up 
possibilities in the diagnosis and prognosis of the war- 
neuroses and in the detection of malingerers, but it can 
only be applied by those few who have at present the 
necessary knowledge and skill to avoid technical fallacies 
and the judicial mind correctly to interpret the facts 
observed and correlate the same with clinical experience. 
Moreover, it appears possible that it might be used as a 



FATIGABILITY TESTED BY ERGOGRAPH 291 

corrective to the interpretation of word-association, as the 
experiment itself is in no way influenced by the mind of 
the observer; thus if the complex discovered by the 
examiner using this method of word-association is the real 
cause of the anxiety; the casual relation in conversation 
of the complex should immediately reveal a marked 
galvano-psychic reaction, and no other suggested complex 
should produce such a marked effect. 

It is necessary to say, however, that the instrument is 
extremely sensitive, and only long and patient obser- 
vation can be regarded as likely to be productive of 
reliable results. It is accurate when the word-association 
is not. 

The Reaction of the Neurasthenic and Hysteric 
Contrasted 

Captain Golla has shown that the psycho-galvanic 
reaction of the hysteric presents a marked contrast to 
the reaction of the neurasthenic. In the hysteric there 
is a lowered sensibility generally, and in some particular 
systems so great is the psycho-sensory dissociation as to 
cause a loss of function; thus we may have deafness, 
blindness, or absence of the kinaesthetic sense, and aphonia, 
mutism or paralysis may result. 

The hysteric who shows a psycho-galvanic reaction less 
than the normal may, however, exhibit during the experi- 
ment a spurious excessive emotional reaction by respiratory 
manifestations. In fact, it is a subconscious emotional 
simulation. 

It is well known that hysterics are easily moved to tears 
or laughter, and the two may be almost simultaneous, 
showing that there is no depth or intensity of feeling. 
" The silent grief that whispers the o'er-frought heart 
and bids it break " does not enter into the hysterical 
complex. 

The psycho-galvanic reaction of the neurasthenic suffer- 



292 WAR NEUROSES AND SHELL SHOCK 

iiig with an anxiety neurosis presents a psycho-galvanic 
reaction to noises, to pain and to certain word complexes 
which have a relation to his anxiety, much more marked 
than in the normal individual. The psycho-galvanic 
reaction may therefore in the hands of an experienced 
observer be a useful aid to diagnosis and prognosis. 

Captain Golla, working in my laboratory, has shown 
that there is a difference in the ergograph tracing of the 
hysteric, the normal and the neurasthenic. This is well 
illustrated in the tracings. The hysteric does not show 
fatigue, because the pull is much below the normal; the 
neurasthenic differs from the normal in showing the advent 
of fatigue much sooner than the normal. 

It is remarkable that the hysteric's pull by the sound 
limb is considerably less than normal and less than can 
be explained by the condition of his muscles. This fact 
suggests that there is an innate volitional weakness, so 
that a slight emotional shock may cause cortical kin aesthetic 
dissociation and return of the paralysis. 

Fatigue does not show itself in the ergograph tracing 
of the hysteric, because he has not the will to exert him- 
self. There are variations in tension, but these are not 
evidences of fatigue. 

Test of Memory and Responsibility in Officers 
Suffering with Neurasthenia 

The following orders, which an officer might have to 
carry out, are read to him slowly, and he is allowed to 
write the same down, or he may write notes. He is then 
questioned upon the nature of the order. If he makes a 
mistake in any important essential he is easily convinced 
that he is unfit. This test is very useful when applied to 
officers who have not recovered sufficiently and who are 
anxious to get back to the front, for they see then how 
useless they would be and that they are quite unfit for 
any responsible position. 



A. Initial pull 95 lbs. Tracing from normal man exercising maximum 
contraction of hand on dynamometer. Contraction curve shows pro- 
gressive dinainution, and is fairly smooth. 




B. Initial pull 65 lbs. Normal man not exercising full power owing 
to stiff finger joint. Note absence of fatigue curve and rythmic 
oscillations of attention. 



LEFT-HAND. 



RIGHT-HAND. 



iMiiiiiii^^ 



C. Left-hand pull 10 lbs.; right-hand pull 50 lbs. Case of hysterical 
monoplegia of left-hand. The left-hand shows no fatigue curve. The 
right-hand shows typical diminution of power, only 50 lbs., and irregular 
oscillations. No fatigue decline, as full power not exercised. 



ADMONISHED. 



D. Initial pull 85 lbs. Malingerer. Note irregularity of fatigue curve. 
Spurt put on when admonished. Rapidly decreasing again. 




E. Initial pull 50 lbs. Neurasthenic. Note small initial contraction 
with rapid subsidence to small contraction, which is kept fairly level. 



294 WAR NEUROSES AND SHELL SHOCK 

24. X. 191S. 

2nd-Lt. Smith. 

I/c of Night Raiding Party. 

Your party will be at Assembly pt. A 7.5 by 22 hrs. 
24. X. 1918. 

At Zero + 12 you will advance in formation already 
communicated and perform task already given. Care 
should be taken that all wounded are evacuated, and 
time of barrage dropping memorised. 

Acknowledge receipt of message and please destroy 
after perusal. 

O. C. NiGHTLIGHT. 
Bif runner. 
I'ihrs. 15. 

25. X. 1918. 

2nd-Lt. Brown. 

Your party will parade in time to reach C 1.5 by 23 
hrs. 40. 

The work of destroying enemy saphead and method of 
conduct have already been given to you at our conference 
this morning. 

Should unforeseen circumstances arise, you will, of 
course, use your own initiative, although it may involve 
changing the whole method of conduct of operation. 

Impress upon your men, the last thing, that firmness of 
purpose, strict silence, and daring and audacity go far to 
make these local operations a true success in the military 
sense. 

Acknowledge receipt, pleasC, and destroy after perusal. 

O. C. NiGIlTLIGHT. 
By runner. 
15 /ir-*. 60. 

Operation Order No. Ill, " Z " Artillery Group 

22/4/10. 

The 21st Division will attack and capture Pink Line on 
18th May, 1917. Zero hour has been fixed for 14.40. 

" Z " Group. Eighteen-pdr. batteries will provide a 
crec])ing barrage to cover infantry attack in 50-yard lifts 



THE GYMNASIUM IN TREATMENT 295 

every minute, and a standing barrage to protect infantry 
when in occupation of Pink Line, as set forth in table below. 

Task I. All 18-pdr. batteries. 

Angle of sight 10" dep., range 4200, No. 80 fuses. Length 
of fuse, 20 1. 

Zero to Zero 15. Six rounds per gun per minute, lift 50 
yards every minute. 

Zero 15 to 40. Four rounds per gun per minute, 50 % 
H.E. to be used. 

Zero 40 to 50. Three rounds per gun per minute, 50 % 
H.E. to be used. 

Zero 50. Stop, await orders from Group Headquarters. 

J. Smith, 
CAPt. and Adjutant, 

" Z " Artillery Group. 

I ha/ records of these orders and others upon the 
dictaphone, and the officer is asked to listen to the same, 
make notes, and be prepared to remember how to act. 

The Gymnasium in Treatment after Functional 
Paralyses and Contractures 

I am sure that machines employed by doctors as a means 
of making the functional paralytics move their limbs are 
wrong in principle and in practice, and I entirely approve 
of the methods adopted by Col. Deane at the Croydon 
Hospital of restoring function by natural methods, in which 
the mind is exercised. The value of natural and varied 
associated movements, such as we get with the parallel 
bars, the climbing rope, skipping, basket football, punching 
ball, Indian clubs, the nautical wheel, and the ordinary 
apparatus of the old-fashioned gymnasium in the treat- 
ment of convalescent cases of functional contracture and 
paralysis cannot be over-estimated. For these exercises 
have this advantage over machines which move the dis- 
abled limb in the fact that the mind is projected into the 



296 WAR NEUROSES AND SHELL SHOCK 

paralysed limb, and all the sound limbs are being exercised 
at the same time. 

Another advantage of the gymnastic class is emulation ; 
for the effect on the mind of seeing one man perform an 
exercise is to stimulate another to do better. The reader for 
further information is referred to a little book by Col. Deane 
on Gymnastic Treatment for Joint and Muscle Disabilities. 

After-treatment by Occupation 

Diversion of the mind by useful occupation in the work- 
shop, in the garden, and on the farm, have been most suc- 
cessful in restoring health and strength to functionally 
disabled men. 

Now, before discharging soldiers suffering from these 
functional neuroses as permanently unfit, always tell them 
that they must show themselves fit to be discharged, by 
having so far lost their symptoms that when they do return 
to civil occupation, people should not say, " What are those 
blessed doctors doing in discharging a poor fellow in a con- 
dition like this? "; and before they can leave the hospital 
they must give evidence of being in a fit state. I tell 
my patients that I will prescribe for them two hours' 
occupation in the morning in the carpenter's shop. This 
treatment I have been enabled to carry out through 
the generosity and kindly interest of Lady Henry Bentinck, 
who, at her own expense, has built in the grounds at 
Maudsley Hospital a large workshop fitted with every 
appliance for carpentering, cabinet-making, and metal 
work, and with a first-rate instructor. Numbers of officers 
and men are daily employed in this workshop, and almost 
daily Lady Bentinck comes to encourage them by her 
presence, and to supply any need for the successful prosecu- 
tion of the work. The War Office pays for nothing. 

The Maudsley Hospital is situated in extensive grounds 
(for London), and the soldiers, under my direction, did 
much to beautify the waste that followed the building 



AFTER-TREATMENT BY OCCUPATION 297 

operations; they have even made a fountain and flower- 
beds. I utiHsed a large amount of the garden for growing 
vegetables. Among other occupations to be encouraged 
may be mentioned that of poultry keeping. 

As soon as the men show that they are fit to undertake 
light work, we feel that they are sufficiently recovered 
to be discharged from the hospital under the new Army 
Council Instructions, No. 712 of 1918 {vide p. 260), but 
very often we find they suffer from dizziness or they easily 
tire, or say they suffer from dizziness or tire ; but those 
who are too ill to undertake any work should be con- 
sidered too ill to go out on pass. In the carpenter's shop 
the men receive such remuneration as the sale of the articles 
they make, less the cost, brings in; orders for handicraft 
are received by the instructor. Interest in the work is 
thus maintained, which is essential for success in treat- 
ment. There are patients, however, who cannot stand 
the noise of the hammering and tapping, and for such 
cases other occupations, such as shoemaking, bookbinding, 
etc., should be provided. 

Singing classes, under the direction of proper instructors, 
have been a great success in France and in the camps in 
England. The Y.M.C.A. have organised a system which 
might with great advantage be applied to convalescent 
soldiers. Choral singing of good music would, I am con- 
vinced, prove for convalescent soldiers an uplifting mental 
diversion, which by promoting cheerfulness and healthy 
recreation could not fail to beget that sense of well-being 
so essential for mental and bodily recuperation. It would 
be not only of educational value to the soldiers, but in 
after life the acquirement of the art of singing would be 
a source of joy to themselves and pleasure to others when 
they return to active service and civil life. The Vocal 
Therapy Fund has been started to provide teachers of 
singing, and has already commenced to do useful work in 
hospitals and convalescent camps in England. 



BIBLIOGRAPHY 

Babinski : Les Travaux Exposes Scientifiqiies. 

Babinski et J. Froment : Hysterie-Pithiatisme. Collection 
Horizon. 

Bassett, Jones and Llewellyn : Malingering. 

Bastian : Aphasia and Other Speech Defects. 

Bayliss, W. M. : Intravenous Injection in Wound Shock. 
Oliver-Sharpey Lectures, British Medical Journal, 1918. 

Benisty, a : Clinical Forms of Nerve Lesions. Edited by E. 
Farquhar Buzzard. Military Medical Manuals. Univer- 
sity of London Press. 

Bignami and Nazari : Sulle Encefalite emorragiche e sidla 
patogenesi delle emorragie miliariche del cervello. Ri vista 
Sperimentale de Freniatria, Vol. XLII. fasc. I. 

Bing, Robert : Opinions Allemandes sur les accidents nerveux 
determines par VExplosion du Projectile a proximite. 
Schweizer Arch. f. Neurol, u. Psychiat., Band I. Heft 2. 

" Akroclystonie''' als Folgezerstand von Kriegs verletznngen 

der oberen Extremitdten. Schweizer Arch. f. Neurol, u. 
Psychiat., Band II. Heft 1. 

Bonhceffer : Die Dienstbeschddigungsfrage in der Psycho- 
pathologie. Die MilitardrtzlicJie Sachsverstdndigentatigkeit 
auf dem Gebiete des Ersatzwesens und der Militdrischen 
Versorgung. Teil, pp. 86-115. Jena : Fischer. 1917. 

War Experience on the Etiology of Psychopathic States. 

Allegem. Zeitschrift. f. Psych. Ref. Zeitscher. f. d. gesamte 
Neurol, u. Psych., Ref. XIII. 3, 1916. 

BowLBY, Sir Anthony : Wounds in War. Lancet, Dec. 25, 

1915, p. 1385. 
Brill : Psychanalysis. Its Tlieory and Application. 
Brown, Wm.: The Treatment of Cases of Shell Shock in an 

Advanced Neurological Centre. Lancet, Aug. 17, 1918. 
Burton-Fanning, Lt.-Col. : Neurasthenia in Soldiers of the 

Ilortie Forces. Lancet, June 16, 1917. 

298 



BIBLIOGRAPHY 299 

Buzzard, Capt. Farquhar: Warfare on the Brain. Lancet, 

Dec. 30, 1916. 
Charcot : Clinical Lectures on Diseases of the Nervous System. 

Vol. HI. Sydenham Soc. 
Clarke, Mitchell, Lieut. -Col. R.A.M.C. : Some Neuroses of 

the War. Bristol Med. Chi. Journal, July, 1917. 
Crile, G. W. : The Kinetic Drive. Wesley Carpenter Lecture, 

N.Y. Academy of Medicine, 1915. 

Origin of the Emotions. 

Deane, H. E. : Gymnastic Treatment for Joint and Muscle 

Disabilities, Oxford Press. 
Dejerine et Gauckler : Les Manifestations fonctionelles des 

Psycho-nevroses. Masson et Fils. 
DiDE, Maurice M. : Discussion, La Confusion Mentale. Bulletin 

de la Societe Clinique de Medecine Mentale, p. 74, Dec. 

1917. 
DuPRE, M. E. : Psychoses de Guerre. Revue Neurol., Nov.- 

Dec. 1916. Neurologic de Guerre. 
Eager, Major R., R.A.M.C. : A Record of Admissions to the 

Mental Section of the Lord Derby War Hospital, Warrington, 

from June 17, 1916, to June 16, 1917. Journal of Mental 

Science, July, 1918. 
Elliot, Smith, Prof. G. : Shock and the Soldier. Lancet, April 

15 and 22, 1916. 

Farrar, Clarence B. : War and Neurosis. The American 

Journal of Insanity, Vol. LXXIII. No. 4. 
Francais, Henri : Accidents Organiques apparaisant sous 

Vinfluence de la Commotion provoque par la Deflagration a 

distance sans plaie exterieure. Neurologic dc Guerre, Nov. 

1916. Revue Neurol., p. 675. 
Gaupp, R. : Die Dienstbrauchbarkeit der Epileptiker U7id 

Psychopathen. Die Militar., pp. 115-39. 

Neuroses following Injuries in Warfare. Zeitschrift fiir 

die gesamte Neurologic und Psych. Orig., 34, 1916. 

Grosz, Emil V. : Injuries and Diseases of the Eye and Blind- 
ness in War. Ref. The Ophthalmoscope, Aug. 1916, 
Vol. XIV. No. 8. 

Hotchkiss, Major, R.A.M.C. : A War Hospital for Mental 
Invalids. Journal of Mental Science, April, 1917. 

Hurst, A. F., and E. A. Peters : A Report on the Pathology, 
Diagnosis and Treatment of Absolute Hysterical Deafness in 
Soldiers. 



300 BIBLIOGRAPHY 

Kaxt, Immaxuel : Dreams of a Spirit Seer. Translated by 
Emanuel F. Goerwitz. 

Lepine, Jean : La Commotion des Centres Nerveux par Ex- 
plosions. Consideration Pathogeniqve et Clinique. Bull, de 
L'Acad. de Medecine, Vol. LXXV. No. 27, July 4, 1916. 

Leri, Andre : Neurologic de Guerre. Revue Neurol., p. 757. 

Lewis, Tiios., M.D., F.R.S., F.R.C.P., D.S.C. : The Tolerance 
of Physical Exertion as shown by Soldiers svffering from 
so-called Irritable Heart. 

Mairet et Durante : Commotional Syndrome. Presse Mcdi- 
cale, June 15, 1917. 

Mairet et Pieron : The Emotional Syndrome. Its Differen- 
tiation from the Commotional Syndrome. Travaux du 
Centre Neuropsychique de la XVI. Region, 1917. 

Marshaj.l : Explosives : Manufacture, Properties, Tests. 

Meige, Henri: Reformes, Incapacites, Gratifications dans les 
Tremblements, les Tics, et les Spasmes. Neurologic de 
Guerre. Revue Neurol., Nov. 1916. 

Revue Neurologiede Guerre. Revue Neurol., 1917, p. 760. 

MoNAKOW, Von : Die Localisation im Grosshirn. Wiesbaden : 

Verlag von J. Bergmann. 1914. 

Mott, F. W., Lt.-Col. R.A.M.C. : Carbon Monoxide and Nickel 
Carbonyl Poisoning. Vol. III. Archives of Neurology and 
Psychiatry. 

The Effects of High Explosives upon the Central Nervous 

System. Lancet, Feb. 1916. Lettsonian Lectures. 

Punctiform Ilcemorrhages of the Brain in Gas Poisoning. 

Proceedings of the Royal Society of Medicine, 1917. 
Vol. X. pp. 73-90. 

The Microscopic Examination of the Brain of Two 

Men Dead of Commotio Cerebri {Shell Shock) without 
Visible Injury. British Medical Journal, Nov. 10, 
1917. 

Degeneration of the Neuron. Croonian Lectures, June 23, 

1900, p. 1779. 

The Psychology of Soldiers' Dreams. Lancet, Jan. 26 and 

Feb. 2, 1918. 

Mental Hygiene in Shell- Shock, During and After the War. 



Journal of Mental Science, Oct. 1917 
Myers, Chas. J. : Contributions to the Study of Shell Shock. 
Lancet, March 18, 1916. 



BIBLIOGRAPHY 301 

Netter, ' F. : UEpilepsie Generalisie consecutive aux trauma- 
tismes de guerre cranio cerehraux. These de Paris, 1917-18, 
No. 9. 

Norman, Herbert : Stress of Campaign. Review of Neuro- 
logy and Psychiatry, August-September, 1917. 

Ormond : Injuries of the Visual Apparatus. Discussion Oph- 
thalm. Soc. Trans., Voh XXXVII. 

Rivers, W. H. P., Capt. R.A.M.C. : Freud's Psychology of 
the Unconscious. Lancet, June 16, 1917, p. 912. 

RoussY ET L'Hermitte : Psycho-nevroses de Guerre. Collection 
Horizon. 

Salmon, Colonel Thomas W, : The Care and Treatment of 
Mental Diseases and War Neuroses (Shell Shock) in the 
British Army. Mental Hygiene, Vol. I, No. 4, October, 
1917. 

SoLLiER : Du Diagnostique Clinique de V exageration et de la 
perseveration des troubles nerveux fonctionels. Presse Medi- 
cale. No. 62, Dec. 16, 1915. 

Stevenson, Surgeon G. : Note on the Cause of Death due to 
High-Explosive Shells in Unwounded Men. British Medical 
Journal, Sept. 18, 1915, p. 450. 

Stier, E. : Dienstbeschddigung und Rentenversorgung bei Psycho- 
pathen. Die Militdrdrztliche Sachsverstdndigentdtigkeit auf 
dem Giebte des Ersatzwesens und der Militdrischen Versor- 
gung. Erste Teil, pp. 140-74. Jena : Fischer. 1917. 

Waller, A. : Galvanometric Records of the Emotive Response to 
Air Raids, and to Ordinary Stimulation, Real and Imaginary. 
Lancet, Feb. and March 9, 1918. 

Wilson, Gordon, Capt. Canadian A.M.C. : Further Report on 
the Effects of High Explosives upon the Ear. British 
Medical Journal, May 5, 1917, p. 578. 

Wilson, Kineir W. : Concussion-Injuries of the Visual Appa- 
ratus. Trans. Ophth. Soc, Vol. XXXVII, 1917. 

WoLFSOHN, Capt. J. W., M.R.C., U.S. Army : T'he Predisposing 
Factors of War Neuroses. Lancet, Feb. 3, 1918. 

Yealland : Treatment of Some Common War Neuroses. 
Lancet, June 9, 1917. 

Zimmern et B. Longre : De U Utilization en Neurologic du 
phenomene appele Reflexe Galvano-psychique. 



APPENDIX 

Introduction. — ^W^ith the cessation of hostilities there 
has been, as anticipated, a remarkable drop in the number 
of recent cases of war neurosis, especially of mutism, 
aphonia, functional paralysis and contractures. There are, 
however, still in hospitals, convalescent camps and regi- 
mental depots a number of uncured cases. Still more 
numerous are the pensioners suffering with these curable 
disabilities ; some of the cases which have recently come 
under observation at the Maudsley Hospital and have 
been rapidly cured had been receiving pensions for many 
months to several years. Many of these functional dis- 
abilities were associated with wounds and injuries. Although 
the examination of the patient with a view to differential 
diagnosis of functional from organic disease has been 
already discussed, yet my recent experience of pensioners 
has shown that a great many cases of war neurosis are 
associated with injuries and wounds ; it has therefore be- 
come necessary, in awarding pensions, to ascertain how far 
the disability or deformity is due to the injury or wound 
causing an organic lesion of a more or less permanent 
character. For this reason it is felt desirable to summarise 
briefly, in the form of an Appendix, the methods that 
should be employed in making a systematic examination 
of such cases. 

Diagrams, after Erb, of the motor points for electro- 
diagnosis and illustrations of the distribution of the peri- 
pheral sensory nerves, copied from the admirable work of 
A. Benisty, are given to aid the reader in making a thorough 

302 



APPENDIX 303 

clinical investigation of the neuro-muscular system and 
thereby to arrive at a correct diagnosis of the cause of a 
disability and deformity, and its permanence or partial 
permanence. 

Method of Examination 

1. Pre-war History of the Patient. — The importance of 
ascertaining the existence of an inborn neuropathic or 
psychopathic tendency by a careful inquiry into the family 
history has been already emphasised in discussing the 
subject of war neuroses, but it may be pointed out that 
such information is especially necessary for determining 
how far the disability is due to a constitutional condition, 
therefore not attributable to, or aggravated by, military 
service. Again, it is necessary in the award of a pension 
or a gratuity to elicit facts in the history which may 
point to the existence of a disability or nervous disease 
prior to the patient having joined the service. The mental 
capacity may be, in a measure, judged by the standard 
reached in the board school, the occupation, and the wage 
earned prior to military service. 

2. The Military History. — To ascertain this, the following 
questions should be asked : — 

Length of service ? 

When called up ? 

Previous service or occupation ? 

Did the patient join voluntarily or was he conscripted ? 

Length of service abroad ? 

Nature of the service ? 

The most useful information is obtainable from the 
soldier's field-card. In the case of war neuroses and shell 
shock, the information regarding the nature of the case 
may be accepted as accurate, for the diagnosis is made by 
a neurologist first hand; any statement made by the 
patient that does not accord with it may, as a general 
rule, be disregarded. In cases of wounds and injuries of 



304 APPENDIX 

the body associated with paralyses and contractures, the 
following particulars should, if possible, be ascertained : — 

(a) Details of the Injury 

When it happened? 

How it was caused? 

What were the immediate results ? 

Especially was there loss of consciousness or collapse ? 

Was there paralysis or loss of sensibility, and if so, what 
parts were affected ? 

Was he able to walk to the CCS. ? 

Was an operation performed ? Was the bullet or piece 
of projectile removed ? 

Was an operation of nerve suture performed ? 

Was there a fracture ? 

If so, was it put on a splint, or put up in plaster, and 
for how long? 

Was anti-tetanic serum given, and if so, when ? 

(b) Subsequent History 

Inquiries should be made regarding the occurrence of 
secondary haemorrhage, suppuration, and if any further 
operations were performed. 

If the paralysis or contracture came on some time after 
the injury, the examiner should try to elicit a cause, mode 
of onset, and subsequent progress, stationary condition or 
retrocession. 

Was a skiagraph taken, and if so, what was the result ? 

If there is .a joint fixation, its probable cause and 
development should be inquired into, also whether the 
after-treatment of wounds by splints, massage, etc., was 
without skilled surgical supervision. 

The existence of trophic, vaso-motor and secretory dis- 
turbances should be investigated as to their onset and 
progress, and especial attention should be given to the 



APPENDIX 305 

atrophy of muscles, and the length of time the patient 
has used crutches or sticks, or appliances to correct a 
deformity. 

Examination of the Patient 

The attitude, gait, station and sitting posture of the 
patient should be noted when he is aware and unaware 
that he is being observed. Also when he is undressing 
and dressing, for valuable information regarding simula- 
tion and exaggeration can often thus be obtained. The 
facial expression, and any abnormality in speech, should 
be recorded. The condition of the pupils, regarding size, 
inequality, irregularity and reactions to light and accom- 
modation should be observed as a matter of routine. The 
existence of ocular paralysis and evidence of nystagmus 
are also important indications of organic disease and 
should lead to further neurological investigation, including 
ophthalmoscopic examination. 

In many cases the history may show that the patient 
should be partially or completely stripped, and a careful 
inspection of the body made for scars of healed wounds, 
fractures, dislocations and deformities. 

The relation of cicatrices, of entry and exit in cases of 
gunshot wounds, to the anatomical situation of nerves and 
the possibility of their severance or injury, should be 
determined. Again, the involvement of muscles, and par- 
ticularly of tendons in deep-seated fibrous induration in 
the neighbourhood of cicatrices, and the possibility of 
limitation of movement thereby, should be considered. In 
cases of fracture, not only must the disability of move- 
ment, and the deformity caused thereby, be taken into 
account, but the possibility of pressure on the nerve by 
callus. Limitation of joint movement may be due to a 
fracture, to dislocation, to arthritis, or to adhesions and 
fibrous changes in the contracted muscles and tissues 
around the joint from prolonged immobility. 

X 



306 APPENDIX 

Motor Function 

The existence of muscular atrophy and fibrillary tremor 
should lead to further neurological investigations regarding 
the groups of muscles so affected. The contracture of the 
atrophied muscles should be tested by comparative palpa- 
tion of the affected muscles and those of the opposite side, 
when movement is attempted or performed with and 
without resistance. 

When there is muscular atrophy of a limb, the amount 
of wasting should be estimated by careful measurements, 
and a comparison of them made with similar measurements 
of the sound limb. The electrical reactions of the muscles 
on the two sides should be tested {vide Electro-diagnosis). 

The mobility of the joint should be tested by active and 
passive movements {vide The Orthopoedic Exercises). 
Should fixation of any impairment of movement be 
observed upon passive movements, the existence of arthritic 
changes must be considered and an X-ray examination 
should be made. It must be borne in mind that muscular 
atrophy and organic changes in and around the joint 
readily arise from prolonged immobility. A wounded limb 
without nerve lesion, which has been immobilised by the 
prolonged use of a splint, may be affected by a contracture 
and paralysis. 

A systematic examination of the electrical reactions of 
the muscles, the application of tests to determine the 
functional integrity of the sensory nerves, and a careful 
investigation of the superficial and deep reflexes in such 
cases, will enable one to differentiate organic from func- 
tional disease. In cases where organic and functional con- 
ditions coexist, such an examination will determine how 
far the disability is curable by physio-psychotherapy; 
moreover, a judgment regarding the amount of residual 
permanent disability can be made, and compensation by 
gratuity or pension can then be properly assessed. 



APPENDIX 307 

The Investigation of Sensibility 

The investigation of sensibility may be conducted by 
simple methods of testing, but to obtain accurate records 
patience is required on the part of the observer and the 
observed. It is advisable not to weary the patient, for it 
is necessary to have his attention to obtain reliable results. 
It may be desirable to make several trials before coming to 
a conclusion regarding the exact topography of the sensory 
defects. The patient's eyes should be closed, or he should 
be prevented from seeing the part which is being tested. 

Objective Disturbances. — Cutaneous or superficial sensi- 
bility and deep sensibility should be tested. The former 
includes tactile, painful and thermal sensibility of the 
skin, and each should be tested in cases of wounds asso- 
ciated with paralysis and contracture. The cases of skin 
affected by a partial or complete loss of sensibility to 
stimulation should be mapped out with a dermographic 
pencil, and the same denoted on a chart. When the chart 
is complete it should be compared with the accompanying 
diagrams illustrative of peripheral sensory distribution of 
the upper and lower extremities and of areas of sensory 
changes in lesions of the peripheral nerves. Injury of 
spinal roots will give a quite different distribution of 
sensory disturbance, and the reader is referred to the 
table opposite p. 176 for information thereon. For sensory 
changes in hysteria vide p. 181. 

Tactile Sensibility.— The skin is lightly touched with a 
wisp of wool, a soft camel-hair brush, or the tip of the 
fingers. The patient is told that he will feel a slight 
touch, and he is to say " Yes " whenever he feels the 
contact. It is better to work from the normal to parts 
in which the sensibility to touch is diminished. A hypae's- 
thetic area surrounds the area of complete tactile anaes- 
thesia. In this area it will be found that the two blunt 
points of a pair of compasses can be separated for a 



308 APPENDIX 

considerable distance and yet give the sensation of but one 
point. Besides observing whether a patient feek the tactile 
stimulus, we should ask him to localise it by placing the 
finger on the point touched. 

Sensibility to Pain. — Sensibility to pain is tested with 
a needle or pin. A useful instrument for rapidly detecting 
analgesia is a dress -pattern perforating wheel with sharp- 
pointed teeth. The wheel can be rapidly run round a 
limb in different regions below the wound, asking the 
patient to say when he ceases to feel a sharp pricking 
sensation. As in the case of anaesthesia, so in analgesia a 
zone of diminished sensibility to pain surrounds the area 
of analgesia. The point of the pin no longer feels a prick, 
but is felt as a touch or dull blunt point, or sensation 
only occurs after some delay. There may be a zone of 
hyperalgesia coinciding in some cases with tactile anaes- 
thesia or hypaesthesia. 

Sensibility to Heat and Cold. — Sensibility to heat and 
cold should next be tested. For this purpose metal tubes 
or wide test tubes containing sensibly hot water (50° C.) 
and ice water are employed. The patient should be asked 
to say " Hot "or " Cold " according to the sensation pro- 
duced by contact. Around the area of thermoanaesthcsia, 
which usually coincides with the previously charted tactile 
anaesthesia, there is generally a narrow zone of diminished 
sensibility and thermal discrimination. Sometimes in this 
area there is at first only the feeling of contact of the hot 
tube, but this may subsequently develop into a painful 
and persistent burning sensation. 

Deep Sensibility. — Deep sensibility may be tested in 
three ways, viz. (1) sensibility to pressure; (2) sense of 
passive movements and posture; (3) bone sensibility. 

(1) The sensibility to pressure may be tested by the 
head of a pin. In some cases within an area where the 
cotton wool is not felt pressure with this, or the tip of 
the finger, is recognised and correctly localised. 



APPENDIX 309 

(2) The sense of position of joints may be tested by the 
observer making a number of passive movements of an 
affected limb, and asking the patient to follow with the 
sound limb the various movements and postures so 
affected. 

(3) Bone sensibility. To test bone sensibility a large 
tuning-fork, capable of giving powerful vibrations for more 
than a minute, is employed. The fork is made to vibrate, 
and its base is placed upon bony surfaces lying close 
beneath the skin. 

Stereognostic Perception. — Normally a patient should be 
able to recognise familiar solid objects, such as a key, a 
knife, or a penny when placed in the hand without seeing 
them. But from impairment of sensation in some cases 
of peripheral disease, or owing to defective cortical per- 
ception occurring in certain morbid conditions of the 
brain, the patient may feel the presence of an object yet 
cannot tell what it is without seeing it. 

Subjective Disturbances of Sensibility. — The most impor- 
tant is pain. The patient should be interrogated as to the 
nature of the pain, whether stabbing, burning, shooting 
or pricking ; whether it is continuous or paroxysmal, local- 
ised or general. If localised, the endeavour should be 
made to ascertain whether the pain corresponds to the 
areas of distribution of peripheral nerves or posterior 
roots. When pain is complained of it is important to 
ascertain whether it occurs spontaneously or is provoked 
by pressure on a nerve, or a healed scar over a nerve. 

Many neurasthenic patients complain of pains and 
other subjective disturbances of sensibility such as numb- 
ness and formication, but these sensory symptoms are also 
common in organic disease and lesions of the nervous 
system, and when they occur they should only be regarded 
as of functional origin, after exclusion of the existence of 
organic disease by an examination of the superficial and 
deep reflexes. 



310 



APPENDIX 



PERIPHERAL SENSORY NERVE DISTRIBUTION OF 
THE UPPER AND LOWER LIMBS (after Benisty). 



Superficial cervical plexus. 



Circumflex, 



lutercostals. 



Mnsculo-spiral 
Lesser iutAmal cutaneous. 
Internal cutaneous. - 

Muscolo-cutaneous. 



Median 
(palmar cutaneous nerve) 

Median 
(collateral nerves of fingers). 

Ulnar 
(superficial terminal branch) 




Fig. 1. — Peripheral sensory distribution of the upper 
extremity (pakn^r aspect). 



APPENDIX 



311 





312 



APPENDIX 




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APPENDIX 



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APPENDIX 






Fia. 8. — Peripheral sensory distribution of the foot. 



APPENDIX 315 

The Reflexes 

Cutaneous Reflexes. — ^A routine examination of the abdo- 
minal reflexes and the cutaneous reflexes of the lower 
extremity should be made in all cases, as they are of 
extreme importance in the differential diagnosis of func- 
tional and organic disease. 

The Plantar Reflex. — Of all the superficial reflexes this 
is of the greatest practical importance, and therefore it is 
well to give details how it may be best obtained. The 
patient should be lying down on a couch or bed, and the 
limb to be tested is partially flexed at the hip and knee 
and rotated out a little. The outer side of the sole of the 
foot is now stroked with the head of a pin from the heel 
to the toes. If stroking the outer side produces no result, 
the middle of the sole or its inner side should be stroked. 
Under normal conditions there is flexion of the toes, but 
when there is degeneration of the pyramidal tracts a slow 
extension (dorsal flexion) of the great toe occurs, which 
may or may not be accompanied by fanning of the other 
toes. This is known as Babinski's sign. 

Oppenheim's sign may be tried if Babinski's sign cannot 
be obtained. This is an extensor movement of the great 
toe evoked by strong friction of the muscles on the inner 
aspect of the tibia. 

A visible contraction of the tipper and outer aspect of 
the thigh usually accompanies the toe movements produced 
by plantar stimulation. 

The Cremasteric Reflex. — This reflex is obtained by 
stroking the inner surface of the thigh from the groin to 
the knee ; retraction of the testicle may be produced. 

The Abdominal Reflex. — In young adults, whose abdo- 
minal walls are apparently normal, absence of this reflex 
is important evidence of organic disease of the central 
nervous system. The patient should be recumbent and 
the muscles of the abdominal wall quite relaxed. The 



316 APPENDIX 

abdomen is then stroked with the blunt point of a pin 
from the margin of the ribs downwards; a reflex con- 
traction should be observed in the superior, median and 
inferior regions of the abdomen. 

There are no important cutaneous reflexes of the upper 
extremity. 

The Deep Reflexes. — Only those will be described which 
are essential for a clinical examination. 

Lower Extremity 

The two important reflexes are the knee jerk and the 
tendo Achillis jerk. There are other less important tendon 
reflexes which can be obtained by percussion of their 
respective tendons at the ankle, viz. reflexes of the tibialis 
anticus, tibialis posticus and peronei. 

The Knee Jerk. — The knee is kept in a position of semi- 
flexion, either by crossing one leg over another, or with 
the foot resting on the ground. The left hand of the 
observer should be applied to the front of the thigh so as 
to be able to feel the slightest contraction of the quadriceps 
extensor. If it is not obtained the patient is told to look 
up to the ceiling, and with his hands clasped in front, he 
is told to pull while the patellar tendon is struck with the 
percuss or. 

The Tendo Achillis Jerk. — The patient is told to kneel 
on a chair with the feet projecting over the edge. He is 
then told to relax the muscles of the leg. The foot is 
now lightly held at a right angle by the left hand of the 
observer, and the bare tendon is struck with the percussor. 
The advantage of the observer holding the foot is that the 
slightest reaction can be felt; moreover, it avoids the 
possibility of a movement of the whole foot being mistaken 
for a reflex contraction. 

Upper Extremity 
Tendon Reflexes. — The principal reflex is the triceps. 
To obtain this reflex the patient is told to let the arm 



APPENDIX 317 

hang quite loosely by the side of the body; the observer 
then takes the wrist of the patient and flexes the elbow, 
asking the patient to keep the muscles relaxed; he then 
percusses the tendon of the triceps just above its insertion 
into the olecranon. An extension of the forearm at the 
elbow is the response. 

The Wrist-tap Contraction. — The elbow is semi-flexed; 
the wrist must be thoroughly relaxed and the hand placed 
midway between pronation and supination. The wrist is 
now percussed on the stylo-radial process. Normally this 
causes a contraction of the flexor of the elbow, viz. the 
biceps, brachialis anticus and the supinatus longus. 

Electro-Diagnosis 

An electrical examination of the neuro-muscular system 
may establish one of three conditions : — 

(1) The muscles and nerves react normally. 

(2) The reactions may present quantitative changes from 
the normal. 

(3) The reactions may present qualitative changes. 

For diagnostic purposes the three most important forms 
of electricity are the faradic, interrupted or induced, the 
galvanic or continuous, and the condenser discharge. As 
a rule the faradic, interrupted or induced current, is all 
that is necessary for practical purposes. 

To test the contractibility of a muscle the patient is 
placed in a recumbent position on a couch. The part to 
be tested is moistened with warm water or salt water. A 
large well-moistened flat electrode is placed over an in- 
different part of the body, such as the upper part of the 
spine for testing the upper part of the body, and over 
the lumbar spine for the lower part of the body. The 
active electrode, well moistened, should be small, f in., 
and this is applied to the various motor points indicated 
in the figures. These represent positions at which the 



318 APPENDIX 

maximum effect can be obtained with comparatively weak 
currents. The strength of the currents should be tried on 
oneself, as it reassures the patient. The motor points can 
best be learnt by practising upon oneself. In the case of 
unilateral' neuro-muscular affection, it is best to test the 
muscles on the sound side and then see whether the 
reaction is obtainable by placing the electrode on corre- 
sponding points on the affected side. If there is no 
reaction the current can be increased in intensity by 
gradually sliding the secondary coil up towards the primary. 
When very strong currents have to be employed to excite 
a contraction in a diseased muscle, there is a difficulty in 
observing whether a reaction occurs, due to the current 
overflowing into surrounding unaffected muscles which 
contract forcibly and mask the feeble contraction of the 
affected muscle. It is advisable, therefore, to localise the 
effects of the faradic excitation by applying two small 
electrodes directly over the muscle to be tested. 

The comparative effects of stimulation of similar motor 
points on the two sides may show three conditions of the 
affected side : — 

(1) The faradic irritability may be diminished; (2) it 
may be lost even with the strongest current; (3) if the 
strength of current necessary to excite a minimum con- 
traction in the muscle of the sound limb causes a more 
obvious contraction on the affected side, faradic irritability 
is increased. 

The active electrode may be placed on the nerve, provided 
it is superficially situated, and the resulting contraction 
noticed. 

Should the faradic interrupted current not give a normal 
reaction the constant current may be employed, and we 
may find correspondingly decrease, increase, or loss of 
excitability. 

A normal muscle responds briskly to galvanic stim- 
ulation. A slow, diffuse and worm-like contraction is 



APPENDIX 



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APPENDIX 



Anterior crural nerve 

Obturator nerve 

JI. i^ectliiajiis 

M. adductor magnus 

M. adduct. longus 

M. cruralis 
M. vastus intemus | 




}"• 



tensor fascleo latss 



M. sartorius 

M. quadriceps femoi'is 

(common point) 
M. rectus femoria 



y- 



I. vastus cxtcmua 



Fig. 10. — Motor Points of Anterior Thigh Muscles. (Elrb.) 



M. tibial, antic. 
M. eztens. digit, comm. 
long. 



M. peronseus brevis' 



H. extensor hallucis- 
long. 



Mm. interossei dorsalos I 




Peroneal nervt 

51. gastrccnem. (outer head) 
M. peronasus k)ngu8 



M. solcus 



M. flexor ballucis long. 



M. eztens. digit, comm. 
brevis 



M. abductor digit! mia. 
Fig. II.— Motor Points of Leg. (Erb.) 



APPENDIX 



321 



Sciatic nerve 

M. biceps fern. (long head) 

M. biceps fern, (short head) 



Peroneal nerve 
II gastrocnem. (outer head) 

JI. soleua 

M. flexor hallucia Iodd 




|m. glutseus maxlmua 



M. adductor msgnus 
M. semitendinohus 
M. setaimembranosus 



Posterior tibial nerve 

51. gastrocnem. (inner head) 
It. soleus 



M. flexor digitor. comm. 
long us 

Posterior tibial nerve 



Fig. 12.— Motor Points at back of Thigh and Leg. (Erb.) 



M, deltoldeus (pos- 
terior half) 



Muieulo.spiral nerve 
M. bracial. antic. 

M. supinator long. 

M. radial, ext. long. 

M. radial ext. brev. 

M. extensor digit. / 

communis \ 

M. extensor Indicis 
M. abductor pollio. long, 
M. extensor pollic brev. 



M. inteross. dorsal, 
I. et II. 




M. triceps (long head) 



j-M. triceps (outer head) 



M. extensor carpi ulnarl 
M. supinator brevis 

M. extensor digit! minimi 
M. extensor indicis 



=:}m. 



extens. poll. long. 



M. abduct, digit, min. 

M. irteross. dorsal. 

III. et IV, 



Fig. 13. — Motor Points of Upper Limb. (Erb.) 



322 



APPENDIX 



M. tricepe (long head) 

U. triceps (inner head) 
Ulnar nerve < 



M. flexor carpi ulnars.' 

JH. flex, digitor. communl 
profund. 



M. flex, digitor, sublim. 
(digitiir. etlll.) 
U. flox. digit. subL (digit, 
indicia et minimi) 

Ulnar nerve 

M. palmaris brov. 

M. abductor digiti min. 

M. flexor digit, m n, 

M. opponens digit, min. 

Mm. lumbricalea 




M. deltoideus 
(anterior half) 



Musculo-cutaneout 
rurve 



M. biceps 
brachii 

M. brach. 
anticuB 



Median nerve 
M. Bupinator longua 

M. pronator teres 



M. flex, carpi radialia 

M. flex, digitor. aublim. 

M. flex, pollicis longoa 
Median nervt 

M. abductor polllc. brev. 
M. opponens pollicis 

M. flex. poll. brev. 

M. adductor polllo. 



Fig. 14. — Motor Points of Upper Limb. (Erb.) 



M. rectus ftbdo- 
minis {Abdo- 
minal intercogtat 
nertes) 




M. serrat. ma^ 
ML latlsBimus 
dorfii. 

IK. obliquus 
abdoxa. eztemos 
{Abdo~ninal 
intercostal nerves) 

M. transversua 

Y\ abdominis. 



Fig. 15. — Motor Points of Abdominal Wall. (Erb.) 



APPENDIX 323 

characteristic of degeneration. In fact, a sluggish con- 
traction of a muscle to the galvanic current is a far more 
reliable indication of degeneration than the much-talked-of 
anodal closure contraction. 

The condenser is now used extensively for testing 
quantitatively and qualitatively the reaction of muscles. 

The Condenser 

The use of the condenser discharge is gradually super- 
seding any other method of electrical testing. It affords 
more accurate information, and the results obtained can 
be expressed quantitatively. When the muscles are rela- 
tively inexcitable it is less painful than other forms of 
stimulation. The procedure advocated by Doumer, at the 
International Congress of Barcelona, 1911, should be 
adopted. 

A large indifferent electrode and a stimulating electrode 
of 2 sq. cm. are used. The electrodes are moistened with 
normal saline. 

The exciting electrode is placed over the nerve, and the 
results are compared with those of the sound limb. The 
current is alternatively reversed, so as to give results for 
+ and — electrodes. 

The characteristic of Intensity is obtained by first 
determining the potential necessary to produce a minimal 
contraction with a condenser of 10 M.F. (Micro-Farads) =V, 
and then finding the limen with a condenser of the same 

capacity but with a resistance of 2000 ohms introduced = V". 
. . Y" _ y 
Characteristic of intensity, I, = milliamperes. 

To find the characteristic of Quantity, Q, the potential 
necessary to produce a minimal contraction with a con- 
denser of yV M.F. is found to = V. 

V — V 

The characteristic of quantity, Q, = micro- 

coulopibs. 



324 APPENDIX 

The characteristic of Time is the most important. 

Characteristic of time, T, = ^ in thousandths of a 

1 

second. 

The reaction of degeneration may be complete or partial. 

In complete degeneration the faradic irritability is abol- 
ished, and the galvanic irritability is either increased or 
abolished. If a contraction occurs it is a sluggish, worm-like 
response, and the anodic closure contracture, A.C.C., is cither 
equal to or greater than the kathodic closure contraction. 

In partial reaction of degeneration there is decreased 
faradic and galvanic irritability of the nerve, and decreased 
irritability to faradism in the muscle. Galvanic irritability 
of the muscle may be decreased or increased, and the 
contraction is sluggish and worm-like. 

Clinical Examination of a Nervous Case 

Only sections applicable to the case need be fully noted 

Patient complains of : — 

History of Present Illness : — 

Past History : — 

Family History : — 

General Condition : — Nutrition. Build. Physiognomy. 

Examination of circulatory, respiratory and urinary 

systems. 
Cranial Nerves : — 

I. Smell. — Test each nostril separately (peppermint, 

oil of cloves). 

II. Vision. — Impairments of visual fields. Chart. 

Colour vision. Fundus oculi. Note errors of 
refraction. 

III. IV. VI. Reaction of pupils to light. Consensual 

reflex. Reaction to accommodation. Equality. 
Shape and size of pupils. Movements of eyes. 
Presence and nature of diplopia. Presence of 
nystagmus, in what direction. 



APPENDIX 325^ 

V. Motor. — Deviation of jaw on opening mouth. Con- 
traction temporals on closing jaw. Contraction 
floor of mouth on swallowing. 
Sensory. — Trigeminal area. Taste. 

VII. Contraction of upper and lower facial muscles, 
screwing up eyes and showing teeth. If para- 
lysed, whether to both voluntary and emotional 
movements. 

VIII. Hearing. — Aerial and bone conduction. 
Vestibule. — If giddiness is present, test on 

rotating chair. 

IX. X. XI. Movements of palate, pharynx, vocal 

cords. Deglutition. Nervous disorders of heart 
and abdominal viscera. 
XII. Movements of tongue. 

Muscular System : — 

A. Upper Extremity. 

General. — Wasting. Development. Hypertrophy. 

Electrical reaction of affected muscles. Tonus. 

Spasticity or rigidity. 
Movements. — 

(1) Shoulder Joint. — Adduction, abduction, 

pronation, retraction, rotation in and 
out, elevation, circumduction. 

(2) Elbow Joint. — Flexion, extension. 

(3) Wrist Joint. — Dorsiflexion, flexion, ever- 

sion, inversion, pronation, supination. 

(4) Fingers. — Flexion, extension, adduction, 

abduction. 

(5) Thunfib. — Apposition, circumduction, flex- 

ion, extension. 

B. Lower Extremity. 

General. — Wasting. Development. Hypertrophy. 
Electrical reaction of affected muscles. Tonus. 
Spasticity or rigidity. 



326 APPENDIX 

Movements. — 

(1) Hip Joint. — Flexion, extension, abduction, 

adduction, eversion, inversion. 

(2) Knee Joint. — Flexion, extension. 

(3) Ankle Joiw^-^Dorsiflexion, extension, in- 

version, eversion. 

(4) Toes. — Flexion, extension, abduction, ad- 

duction. 

C. Head and Neck. 

Movements. — Flexion, extension, inclination, ro- 
tation. 

D. Spinal Muscles. 

Curvatures of spine. Rigidity. 
Movements. — Flexion, extension, rotation, lateral 
movements. 

E. Abdominal Muscles. 

Equality of contraction. Lateral or vertical 
movements of umbilicus. 

F. Co-ordination. 

Of upper and lower extremities with eyes open 
and eyes shut. Tremors, coarse or fine. Gait. 
Rhomberg's symptom. 

Sensory System : — 

A. Objective Examination. 

Note loss of touch sensation (cotton-wool test). 

Note loss of pain sensation (pin prick). 

Note loss of thermal sensation (hot and cold test 

tubes). 
Make charts of areas affected. 
Stereognostic sense — recognition of objects. 
Muscle sense — ^sense of passive movement. 



APPENDIX 327 

Localisation of touch. 
Bone sensation — tuning-fork test. 
Hypersensitiveness to pain and pressure. 
Loss of bladder, rectal or sexual sensations. 

B. Subjective Examination. 

Note distribution of pain, referred pain, parses - 
thesia, formication, numbness. 

Sphincters : — 

Urinary. — Reflex incontinence. Precipitate or delayed 

micturition. Overflow incontinence. 
Rectal. — Reflex incontinence. Paralysis of sphincters. 

Reflexes : — 

A. Deep. 

(1) Upper Extremity. — Triceps and supinator 

jerks. 

(2) Lower Extremity. — Knee jerk. Achilles 

jerk. Note presence of clonus. 

(3) Jaw jerk. 

B. Superficial. 

Abdominal and epigastric. 
Plantar reflex — flexor and extensor. 

Speech : — 
If Aphasic — 

Does patient understand what he hears ? 

Does patient understand what he reads ? 

Can he write to dictation ? 

Can he write spontaneously ? 

Can he name objects ? 

Can he understand use of objects ? 
Note stammer and dysarthria. 



328 APPENDIX 

Psychical : — 

Note general intelligence, memory, dreams. Note 
whether emotional, hypochondriacal, euphoric. If 
delusions or hallucinations. 

Trophic Disturbances : — 

Trophic ulcers, joint and bone changes. Cutaneous 
disturbances. 



INDEX 



Abdominal reflex, how obtained, 315 
Abdominal wall, motor points of 

{illusL), 322 
Acapnia, in relation to wound shock, 

20 
Accommodation, failure of, 188 
Accoucheur hand, see Main accoucheur. 
Acidosis, as cause of shock, 22 
Aero -contracture, 153, 154 
Acro-cyanosis, and shock, 122 
mechanism of production of, 275 
of neurasthenia, 194 

{Ulust.), 194, 195 
treatment of, 274 
Active service, neurasthenia, shell 
shock and functional disorders 
in relation to, 260-2 
pre-war conditions to be differ- 
entiated from conditions due to, 
267 
Adrenal exhaustion, in relation to 

wound shock, 20 
Adrenalin, and blood -pressure, 20, 21 
increased quantity in circulation 19 
Aerial torpedoes, explosive force of, 24 
Agorophobia, 207 

Air, deoxygenation of, by high ex- 
plosive shells, 28 
Air pressure, from explosives, 27 
abnormal, effects on central ner- 
vous system, 28 
death due to, 4, 27, 67 
eye lesions due to, 73 
haemorrhage into lungs from, 38 
repercussion of, 38 
Alcohol, action on the nervous sys- 
tem, 224 
as a food, 225 
influence in the production of war 

neuroses,' 222 
judicious use beneficial in warfare, 
224 
Alcoholism, a predisposing factor of 
shell shock, 109, 110 
chronic, effects of, 226, 227 
frequency of, 225, 226 



Alcoholism, chronic, inborn mental 
instability predisposing to, 226 
suicide in relation to, 226, 227 
symptoms of, 228 
Alphabet, in treatment of stammering 

and stuttering, 285 
Amnesia, anterograde and retrograde, 
80 
case illustrating, 86 
causal mechanism, 14 
complete, case of shell shock fol- 
lowed by, 82 
complicated by choreiform move- 
ments, case illustrating, 85 
confounded with unconsciousness, 

84 
due to gas poisoning, 256 
following shell shock, 89 
periodic, cases illustrating, 89, 90 

causes and characteristics, 90 
psychogenic nature of, 89 
retrograde, 84 

associated with shock, 14, 31 
return of musical memory in severe 

cases of, 91, 92 
shell shock in relation to, 84 
Anaesthesias, 181 
Analgesias, 181 

physio -psychotherapy of, 286 
Anatomical changes, in shell shock, 

49-61 
Anergic stupor, 81 
Anger, effect on the circulation, 19 
Angina, pseudo-, in cardiac neuras- 
thenia, 193 
Anuria, hysterical, 188 
Anxiety, expression of, 82 

paroxysms of, 206 
Anxiety neurosis, cases in which 
common, 139 
See also Neurasthenia. 
Aphasia, motor, hysterical mutism 

as an instance of, 103 
Aphonia, 94 

and mutism, distinction between, 
102 



329 



330 



INDEX 



Aphonia, causation, 102 
gal vano -psychotherapy of, 101 
treatment of, 282 
Arms, exercises for, 281 

hysterical hemiplegia and contrac- 
ture of, 142 
hysterical paralysis of (illust.), 

143-5 
motor points of (illitst.), 321, 322 
penetrating bullet wound, disability 
cured by suggestion (illust.), 264 
peripheral sensory nerve, distribu- 
tion of (illust.), 310, 311 
shell shock with weakness and 
inco -ordination of, case illustrat- 
ing, 95 
tendon reflexes of, how obtained, 
316 
Army Medical Boards, orders in rela- 
tion to neurasthenia, shell shock 
and functional disorders, 260-2 
Amoux, on sudden death due to high 

explosives, 27 
Arterial embolism, organic disease 

arising from, 173 
Arteries, cerebral, structure and dis- 
tribution of, 237 
Arterioles, paralysis of, wound shock 

in relation to, 21 
Articulate speech, diagram illustrat- 
ing twofold mechanism of, 106 
Aschaffenburg, on shell shock from 

windage, 69 

Astasia -abasia, ataxic, 157 

(illust.), 157 

characteristics, 156 

paralytic, 156 

Asthenopia, 188 

Asthma, respiratory difficulties simu- 
lating, in cardiac neurasthenia, 
193 
Ataxia, in subjects of neurasthenia 
or hysteria, 155 
symptoms, 156 
Ataxic astasia-abasia, 157, 158 

(illust.), 157 
Atmosphere of cure, 199, 275 

production of, 271 
Atmospheric pressure, see Air pressure. 
Atypical tremor, 160 
Auto-intoxication, relief of, 269 
Autonomic centres, influence of emo- 
tion on, 18, 19 
Axons, changes in, from concussion, 
10 
characteristics and function of, 6, 

7 
colloidal substance of, 13 



Babinski, definition of hysteria by, 
130 
diagnosis of hemiplegia by, 167 
plantar extensor sign of, 168, 171 
how obtained, 315 
Back, exercises for, 281 
Basophile staining, 10, 11 
Bastian, on aphasia and hysterical 

mutism, 101, 103 
Bath, warm, in treatment, 269 
Battle hypnosis, use of the term, 

110 
Bell's palsy, functional facial paralysis 

simulating, 140 
Benzoin and menthol inhalations for 

effects of irritant gases, 259 
Bing, on shock by windage, 68 
Blepharospasm, characteristics and 
causes, 163 
continuous, 29 
due to irritant gases, 259 
following conjunctivitis due to 

mustard gas (illust.), 163 
treatment, 259 
Blindness, and deaf mutism, case of 
recovery from, 184 
associated with recurring attacks 

of mutism, 102 
atmosphere of cure in, 199 
following shell shock, 186, 187 

case illustrating, 187 
from proximity to shell explosions, 

71, 72, 73 
functional, 7, 14, 29 
hysterical, treatment of, 282 
Blood, affinity of carbon monoxide 
for haemoglobin of, 230 
deoxygenation causing shock, 2 
effect of high explosives on, 4 
Blood changes, in carbon monoxide 

poisoning, 241, 242 
Blood-pressure, fall of, in fatal cases 
of shock, 20 
low, treatment of, 270 
shell shock in relation to, 20, 21 
wound shock in relation to, 20, 
21 
" Blue-funk," 122 
Bomb contusion, 68 
Bombs, destructive power of, 24 
Bone sensibility, how tested, 309 

loss of, 182 ' 
Bowlby, Sir Anthony, on nature of 

high explosive shells, 23 
Brachial monoplegia, case illustrat- 
ing, 143-5 
characteristics and symptoms, 143 
functional (illust.), 147 



INDEX 



331 



Brain, arteries of, structure and 
anatomical relations, 237 
condition in cases of gas poisoning, 

244 
condition in fatal case without 

signs of injury, 46, 47, 60 
effects of irritant gases on, 258 
examination in carbon monoxide 

gas poisoning, 240 
examination in cases of shock, 

cases illustrating, 37, 46, 48 
general paralysis and diseases of ,215 
histological examination, 51, 52 
macroscopical appearances of, 47 
microscopical appearances in cases 
of carbon monoxide poisoning, 
236, 241 
microscopical examination in shell 
concussion with gas poisoning, 
245-7 
microscopical examination of, 47 
of animals, experiments on, 38, 42 
organic diseases of, shell shock in 

relation to, 217 
punctiform haemorrhages in, 249, 
256 
cases illustrating, 246 
causes, 247, 248 

from carbon monoxide poisoning, 
229, 232, 239 
Sep. also Cerebral. 
Breathing, control of, 284 
in treatment of stammering and 

stuttering, 283 
rapid emotional disturbances and, 
193, 194 
Breathing exercises, 280 
Bromide, in treatment, 269, 270 
Bronchioles, action of chlorine and 

phosgene gas on, 248 
Bronchitis, due to mustard gas, 259 
Burial and shell shock, carboa mon- 
oxide poisoning in case of, 238 
Bums, shock from, 20, 66 

Caj.v muscles, contracture of, 154 
Camptocormie, 151 
Capillary stasis, and haemorrhage, 
anatomical relations of the vessels 
favouring, 237 
cause of, 237 

predisposing factor in, 247 
Carbon monoxide gas, detection of, 
257 
explosives producing, 250, 251 
Carbon monoxide poisoning, 228 
action of the gas, 229, 230 
after effects of, 255-6 



Carbon monoxide poisoning, and shell 
concussion, microscopic examina- 
tion of brain in, 245-7 
cause of death in, 250 
causes of production of, 229, 230,251 
causing shell shock, 2 
condition of brain in cases of, 244 
danger of, in mines, 249 
degree tolerated, 230 
detection of, 231 
eilects of, to what due, 249 
efiEects on nervous system, 255, 256 
effects on the heart, 255, 256 
examination of the brain in, 240 
from high-explosive shells, 28 
from trinitrotoluene, 29 
in mines, prevention of, 257 
microscopic appearances in the 

brain, 236, 241 
miliary haemorrhages in, 236 
occujiations in which frequent, 231 
pathology of, 232-6 
pre-war knowledge of pathology of, 

229 
punctate haemorrhages in, 229, 234, 
235 
{illust.), 232-5 
sensory disturbances due to, 250 
soil in relation to, 251 
symptoms of, 239, 252-6 
treatment of, 258 
Cardiac centre, effect of high explo- 
sives on, 3, 4 
Cardio-vascular symptoms, of gas 
poisoning, 255 
of neurasthenia, 192^ 
Carotid artery, aneurism of, 175 
Cells, see Nerve cells. 
Central nervous system, evidence of 

organic disease of, 315 
Cerebral anaemia, in shell shock, 41 
Cerebral arteries, structure and dis- 
tribution of, 237 
Cerebral capillaries, effect of carbon 

monoxide on, 236 
Cerebral commotion, 2, 28 
and memory, 84 

inabihty to exercise sustained men- 
tal attention due to, 86 
psychogenic amnesia following, 89, 

90 
true case of, 67 
visual defects due to, 73 
without signs of injury, 76 
Cerebral congestion, relief of, 269 
Cerebral haemorrhage, 45, 50, 52 
due to explosive power of shells, 23, 
28 



332 



INDEX 



Cerebral hsemorrhago, from high ex- 
plosives, animal experiments, 70, 
71 
in shell shock, 3&-42, 46 
Cerebro-spinal fluid, characteristics 
and function of, 3 
condition in commotional and 

emotional cases, 31 
increased pressure in shell shock 

cases, 268, 269 
violent concussion transmitted to, 
3, 14, 15 
Cerebro -spinal meningitis, case of 
shell shock diagnosed as, 86 
symptoms, 190 
Cervical vertebra, bullet fracture of 

a transverse process, 174 
Charcot, on the nature of hysterical 

mutism, 102 
Cheyne-Stokes breathing, in gas poi- 
soning, 254 
Childlike attitude, following shell 
shock, 81 
case illustrating, 82 
Chloral, in treatment, 269 
Chlorine gas poisoning, symptoms of, 

248 
Choreiform astasia-abasia, 158 
Choreiform movements, 158, 165 
amnesia complicated by, case illus- 
trating, 85 
case illustrating, 166 
characteristics and causes, 166 
•fear and horror causing, 159 
Choroid, rupture due to windage, 72, 

73 
Cigarette habit, 271 
Circulation, cerebro-spinal fluid in 

relation to, 3 
Claustrophobia, 207 
Clinical examination of q. nervous case, 

324 
Clonic spasms, tics due to, 163, 164 
Coitus, of neurasthenics, 196 
Cold, sensibility to, how tested, 308 
Cold sweat, in waking state following 

dreams, 123 
Collapse, description of common case 

of, 32 
Colloidal substance, of nerve cells, II, 

12 
Commotio cerebri, see Cerebral com- 
motion. 
Commotio retinae, due to windage, 72 
Commotion, true, production of, 67 
Commotional shock, and emotional, 
30, 35 
differential diagnosis, 22, 36 



Commotional shock, description of a 
common type of case, 31-33 
emotional shock (severe) following, 

33 
haemorrhage into central nervous 

system, 36 
motor disorders of, 121 
signs and symptoms of, 29-33 
soldiers' dreams in relation to, 120 
symptoms, 68 
Concussion, anatomical changes in, 
62, 63 
due to high explosives, 25, 27 
of internal ear, from high explo- 
sives, 75 
See also Shell shock. 
Concussion blindness, 71 
Condenser, muscle testing by, 323 
Consciousness, degrees of effects on, 85 
oxygen in relation to, 15 
loss of, causation, 15 
Conscripts, see Recruits. 
Consecutive phenomena, of shell 

shock, 36, 78 
Constipation, of neurasthenics, 195 
Contractibility of muscles, how tested, 

317 
Contractures, army discharge and 
pensioners in relation to, 263-5 
cause of pain in, 155 
decrease in number of cases of, 134 
electrical treatment, 278, 279 
following injuries, diagnosis of, 176 
examination of patient, 177 
mechanism of, 134 
functional, differential diagnosis 
from contractures duo to or- 
ganic disease, 172-5, 183 
of hands, feet, shoulder and neck, 
152-4 
gymnasium in treatment of, 296 
hysterical, 139-43 

cases illu.strating, 143-50 
diagnosis of, 167 
of the trunk, 150 

organic lesioas leading to, 132, 183 
reflex, 133-7 
tetanic, diagnosis of, 172 
treatment of, 274 
Contra-suggestion, curing non-hys- 
teric neuropathic symptoms, 130 
functional disorder curetl by, 137 
nature of symptoms cured by, 131 
removal of hysterical symptoms of 

neurasthenia by, 199 
reproduction of symptoms of hys- 
teria by, 130 
treatment by, 276 



INDEX 



333 



Contra-suggestion, treatment by, of 
motor-disabilities^ 158 

Convalescent cases, exercises for, 280, 
281 

Cortex, haemorrhage into, 40 

Cortical anajmia, 41, 42 

Cortical blindness, due to windage, 73 

Cortical centres, higher, shell shock 
chiefly affecting, 84 

Cortical dissociation, symptoms fol- 
lowing shell shock, 15, 16 

Cortical structures, functional dis- 
abiUty in relation to speech, 103, 
104 

Course and progress of the psycho- 
neuroses, 199 

Coxalgia, symptoms of, 219 

Cremasteric reflex, how obtained, 315 

Crile, on pathology and causation of 
shock, 16, 22 

Crural monoplegia, characteristics and 
symptoms, 148 

Crural paraplegia, characteristics, 149 

Cunning, of mahngerers, 218 

Cut throat, and chronic alcoholism, 
227 

Cutaneous reflexes, how examined, 315 

Cutaneous sensibility, how tested, 307 

Dampness, and gas poisoning, 251 
Day dreams, following shock, 79 

case illustrating, 79 
Deaf-mutism, and blindness, case of 
recovery from, 183, 184 
case illustrating, 100 
Deafness, associated with recurring 
attacks of mutism, 102 
atmosphere of cure in, 199 
due to high explosives, diagnosis, 

74, 76 
faradism in treatment of, 282 
following shell shock, cause of, 186 
functional, 8, 14 
hysterical, 186 
mutism without, 99, 100 
nerve deafness, from high explo- 
sives, 74, 75 
temporary, 29 

with and without perforation, 74 
Death, sudden, atmospheric pressure 
in relation to, 27 
theories regarding causation, 4, 24- 

9,46 
without visible signs of injury, 25— 
9, 48, 50 
Deep reflexes, how obtained, 316 
Deep sensibility, methods of testing, 
308 



Deformities, treatment of, 274 
Degeneration, reaction of, how tested, 

324 
Dejerine's definition of neurasthenia, 

130 
Delirium, of action, 204 

during the waking state, 123 
hallucinatory, as sequel of shock, 79 
Delusional insanity, chronic, char- 
acteristics and frequency of, 214 
Delusions, as phenomena of shock, 78 

in chronic alcoholism, 227, 228 
Dementia prsecox, 205 
differential diagnosis, 206 
frequency of, 205 
Dendrons, 6 

attraction and retraction of, 8, 10 
colloidal substance of, 13 
Deoxygenation, by high -explosive 

shells, 28 
Deserters, and epilepsy, 212 
Diagnosis, electrical methods of, 317 
of contractures and paralysis fol- 
lowing injuries and wounds, 167- 
71, 176 
of functional and organic disease, 

172-5 
of idiopathic and traumatic epi- 
lepsy, 209 
of malingering, 217-21 
of neurasthenia, 197, 198 
Diaphragm, function of, 284 
Diaschisis, definition of the term, 8 
theory of, 5-8 
(illust.), 6, 8 
Dide, on neuropathic disorders in the 

wounded, 110 
Digestive disturbances, of neuras- 
thenia, 195 
Discharge of patients from hospital, 

261, 297 
DiscipUne, during treatment, 276 
Disordered action of the heart, 192 
Disseminated sclerosis, gas poisoning 
in relation to, 256 
miners' nystagmus wrongly dia- 
gnosed as, 174 
tremor of, 161 
Dizziness, see Vertigo. 
Dodging reflex, case illustrating, 165 

nature of, 163 
" Double-shuffle," spasmodic move- 
ment, 165 
Dreams, accompanied by fear, 116 
analysis of, 117 
effects of, the next day, 127 
emotional and commotional shock 
in relation to, 119, 120 



334 



INDEX 



Dreams, forgotten, phenomena of, 123 
frequency in series of cases, 1 10 
Freud's theoiy, 117, 118, 119 
in relation to neurasthenia of 

soldiers, 119 
in relation to the unconscious, 118 
nature of, 117 

psychology of, in relation to neuras- 
thenia, 114 
recollection of, 122 
recovery of speech in relation to, 

100 
soldiers', general type of, 125 
terrifying, 79, 86, 95, 114, 118-19, 
124 
factor in treatment of, 199 
socreto-motor and vaso-motor re- 
actions the outcome of, 122 
with incongruous associations, cases 
illustrating, 128, 129 
analysis, 128 
Drift gas, 260 

poisoning by, 240, 248 
Drug habit, insomnia leading to, 191 
Drugs, in treatment, 269, 270 
Dug-outs, effect of explosion in, 38 
Dupre, classification of subjective and 
objective symptoms of nervous 
exhaustion and emotivity, 201-3 
Dynamic conditions of the central 
nervous system, survey of, 3 

Eab, effects of high explosives on, 
71, 74-6 
conclusions from series of cases, 
75 
middle, acute disease of, 76 
Electricity, re-education reinforced by, 
278 
See also Faradism. 
Electro-diagnosis, technique, 317 
Electro-psychotherapeutic treatment 

of tremor, 160 
Emotional association, analysis of 
dreams with incongruous associa- 
tions revealing, 128 
Emotional causes, of exhaustion 

psychoses, 205 
Emotional shock, 131 
and commotional, differential diag- 
nosis, 36 
and hvsterical speech defects, 105 
and physical, 30 
blindness and defects of vision duo 

to, 188 
causation and characteristics, 120 
emotional tremor following, 160 
following commotion, 33 



Emotional shock, motor disorders of, 
121 

soldiers' dreams in relation to, 120 

symptoms, 68 
Emotional tremor, 160 
Emotions, definition of, 120 

expression of the, 103-5 

music appeaUng to the, 93 

origin of, 131 

psychology of the, 18, 19 
Emotivity, and acquired emotivity, 
case illustrating, 34 

classification of symptoms, 201 

dreams in relation to, 119, 120 

galvano-psychic method of deter- 
mining state of, in neurasthenia, 
290 

liability to psycho-neurosis, 29 

morbid, characteristics, 202 

relation of genital functions to, 113 
Endocrine glands, influence of the 
emotions on, 18, 19 

shock in relation to, 22 
Epilepsy, 208 

a predisposing factor of shell shock, 
108, 109, 110 

and hystero- epilepsy, differential 
diagnosis, 210, 213 

and recruits, 209 

arising from shell shock, 208 

desertion in relation to, 212 

disposal of cases of, 214 

examination of patient, 212 

idiopathic and traumatic, differen- 
tial diagnosis, 209 

Jacksonian and generalised, rela- 
tive frequency of, 210 

man-power in relation to, 211 

masked, characteristics, 212 

military service and classification 
of cases of, 211 

observations on, 208 

traumatic, 210 
Examination, clinical, of a nervous 
case, 324 

electrical, of neuro-muscular system, 
317 

for pensions or gratuities, 303, 305 

of malingerers and hysterics, 179- 
81, 182 

of motor function, 306 

of sensibility, 307 

of the patient, 177, 179-82, 267, 
305 

of the reflexes, 315 
Exercises, for convalescent cases, 280 

gymnastic, in treatment, contrasted 
with mechanical appliances, 295 



INDEX 



335 



Exhaustion psychoses, 203-5 
causes of, 204, 205 
classification of symptoms of, 201 
frequency and development of, 
204 
Exophthalmos, frequency in cases of 

shock, 122 
Explosives, see High explosives. 
Expression, of the emotions, 103-5 

mechanism of, 104, 105 
Extensor type, of crural monoplegia, 

149 
Eye, effects of windage upon, 71 
case illustrating, 71-2 

Face, motor points of (iUusL), 319 
Facial paralysis, functional, simulat- 
ing Bell's palsy {illust.), 140 
Facial spasm, and torticollis {illust.), 

164 
Faith, of the patient in treatment, 

200, 268, 275, 276, 277 
Family history, in examination of 
patient, 267 
in series of cases of shell shock, 
109, 110 
Faradic irritability, 318 
Faradism, 278 

examination of neuro-muscular 

system bj', 317 
in hysterical blindness, 282 

hysterical sensory conditions, 281 
mutism, 282 

paralysis and analgesia, 286 
treatment of deafness, 282 
muscle stimulation by, 317, 318 
Fatigue, 189 

frequency in series of cases, 110 
of hysterics and neurasthenics com- 
pared, 292 
Fatty degeneration, in fatal cases of 

gas poisoning, 250 
Fear, and mental conflict, 138, 139 
arousing of, 18 
case illustrating, 16 
contemplative, 120 
effect on the circulation, 19 
effect on the mind, 16 
frequency in series of cases, 110 
morbid, of neurasthenics, 197 
morbid, of psychasthenics, 206, 207 
motor paralysis and disabilities 

associated with, 121 
popular expressions of, 121 
present, past experience associated 

with, 128 
production of tics due to, 159 
state of, 120, 202 



Fear, suppressed, during the waking 
state, secreto-motor and vaso- 
motor reactions the outcome of, 
121 ■ 
tremblings and quakings of, 160 
Feeblemindedness, 207 

frequency in admissions to military 

hospitals, 207 
in recruits, 207 
Fingers, tremors of, in neurasthenia, 
191 
functional paralysis or contracture 
of, 152 
Fits, frequency in series of cases, 110 
Fixed idea, of pain, 178, 179, 180 

of permanent disability, 271 
Flexor type, of crural monoplegia, 148 
Food, alcohol as a, 225 
Foot, functional paralysis or contrac- 
ture of, 152 
peripheral sensory distribution of 

(illust.), 314 
tremor of, test for, 162 
Foot-drop, 152 
Footprints, in re-education, 280 

{illust.), 278, 279, 
Forgetting, mechanism of, Freud's 

theory, 118 
Formication, 309 

Fractures, cases diagnosed as neuras- 
thenia, 198 
Freud's theory, 117 

in relation to treatment by psycho- 
analysis, 287 
mechanism of, 118, 119 
Fright, 205 

See also Fear. 
Fugues, 211, 212 

Functional contracture, see Con- 
tracture. 
Functional disorders, active service in 
relation to, 260-2 
and organic, differential diagnosis, 
172, 173, 183, 197 
reflexes in differential diagnosis 
of, 315 
army discharge and pensioners in 

relation to, 263-5 
diagnosis of, 172-5 
pensions tending to perpetuate, 277 
Functional motor disorders, 132 
Functional paralysis, see Paralysis. 
Functional psycho-neuroses, 5 
Furunculosis, 76 

Gait and station, disorders and dis- 
abilities of, 155 
treatment, 279 



386 



INDEX 



Galvanism, muscle response to, 318 

Galvano-psychic method of investiga- 
tion in hysteria and neurasthenia 
compared, 291 

Galvano-psychotherapy of aphonia 
and mutism, 101 

Games, in later stages of treatment, 
270, 271 

Gas, illuminating, degree of carbon 
monoxide in, 231 

Gas burning, in mines and from im- 
perfect detonation of explosives, 
249 

Gas helmets and masks, 257 

Gas poisoning, from jiigh- explosive 
shells, 26, 27 
See also Carbon monoxide ;Chlorine ; 
Mustard gas ; Phosgene, etc. 

Gases, irritant, effects on the brain, 
268 

Gastro-intestinal symptoms of neu- 
rasthenia, 195 

General paralysis, characteristics and 
diagnosis of, 215 
examination for, 215, 216 
shock exciting onset of, 216 

Genital functions, and neurasthenia, 
113 

Genito-urinary symptoms, of neuras- 
thenia, 196 

Goltz, on cause of shock, 18 

Grave's disease, frequency in cases of 
shock, 22, 122 

Gymnasium, in treatment after func- 
tional paralyses and contractures 
295 

Habit spasm, purposive, production 

by shell shock, 163 
Hajmato-myeha, concussion of spine 

causing, 174, 175 
Haemoglobin, conversion into methae- 
moglobin by nitrous fumes, 
241 
Hajmorrhagcs, due to high explosives, 
animal experiments, 70, 71 
into central nervous system, cases 

of, 36 
into internal capsule, 7 
See also Capillary ; Cerebral ; 
Miliary; Punctate; Spinal. 
Hallucinations, and mental confusion, 
case illustrating, 79 
as phenomena of shock, 78 
characterised by mental enfeeble- 

ment and confusion, 203, 204 
during the waking-state, 123 
in chronic alcoholism, 227, 228 



Hand, condition in median nerve in- 
jury {illusL), 265 
functional injury cured by sugges- 
tion [illust.), 264 
functional paralysis or contracture 
of, 152 
(illust.), 153 

cured by physio-psychotherapy, 
154, 155 
peripheral sensory nerve distribu- 
tion of (illust.), 310, 311 
See also Main accoucheur. 
Hand-grip, in diagnosis of organic 

hemiplegia, 170 
Head, lateral movement of, a common 
spasmodic tic, 165 
case illustrating, 165 
Headache, and vertigo, 81 

as symptom of neurasthenia, 189 
attacks in carbon monoxide poison- 
ing, 235 
characteristics, 189, 190 
frequency in series of cases, 110 
relief of, 270 
Hearing, defects of, see Deafness, 
mental shock accompanying and 
preceding restoration of function 
of, 185 
Heart, disordered and enfeebled action 
of, 45, 192, 193 
wound shock in relation to, 21 
effects of carbon monoxide poison- 
ing on, 236, 255, 256 
examination of, 192, 193 
fatty degeneration in fatal cases of 

gas poisoning, 250 
irntable, 192 
rapid action of, 192 
symptoms of neurasthenia, 192-4 
syncopal attacks in relation to, 
193 
Heat, sensibility to, how tested, 308 
Hebetude, and mental confusion, 80 
Helmets, for gas poisoning, 257 
Hemianalgesia, hysterical, functional 
facial paralysis with, case illus- 
trating, 141 
Hemiplegia, functional, cases illus- 
trating, 147 
functional and organic, differential 

diagnosis, 167-9 
hysterical, development of, 139 
forms of, and their characteristics, 
142, 143 
organic, signs of, 169 
High explosives, air pressure on 
bodies due to, 27 
carbon monoxide from, 229 



INDEX 



387 



High explosives, cases illustrating 
force generated by, 24 
cause of sudden death from, 4 
compression due to, 68 
death from, without visible signs 

of injury, 25-9 
deoxygenation of air by, 28 
dynamics of, 3, 4 
effects in dug-outs, 38 
effects on cardiac and respiratory 

centres, 3, 4 
effects on central nervous system, 

1, 10 
effects on the ear, 74-6 
experiments on animals, 70 
imperfect detonation of, 249 
mutism due to, 94, 95 
nature of, 23 

nature of injuries due to, 23 
producing poisonous gases, 250 
spinal concussion from, without 

visible injury, 175 
theories regarding instantaneous 

death by, 24-9 
vertigo due to, 74, 77 
See also Windage. 
Hill, Leonard, on effects of high ex- 
plosives, 28 
Hip joint, pseudo -arthritis of, 180 
Histological changes, case illustrat- 
ing, 51 
in shell shock, 38-45 
in spinal concussion, 56, 57 
Horror, 82 

causing choreiform movements, 159 
emotion of, with symptoms of 

actual commotion, 36 
nature of, 120 
Hospital, discharge of patients from, 

261, 297 
" Hunger pains," 195 
Hyahne thrombosis, in gas poisoning, 
239, 240, 242, 245 
(illusL), 242 
Hydrobromic acid, in treatment, 270 
Hyperacusis, 187 
Hypersesthesia, 181 
of scalp and neck, 190 
spinal, characteristics, 190 
Hyperthyroidism, frequency in shell- 
shock neurasthenia, 161 
case with signs of, 86 
with periodic amnesia, 89 
Hypnotics in treatment of neuras- 
thenic symptoms, 269 
Hypnotism, in treatment, 276 
Hypochondriasis, in neurasthenia, 197 
Hypothermia, 134, 135 
Z 



Hj'pothermia, local, 133 
of neurasthenia, 194 
treatment of, 274 
Hysteria, and shell-shock, 35 
ataxia in subjects of, 155, 156 
Babinski's definition of, 130 
cause, 112 
class of patient in which common, 

139 
comparative study of personal his- 
tory in series of cases of, 109 
differential diagnosis of, 167-71 
following psychogenic factor of 

shock, 2 
in civil and army Ufe compared. 111 
in recruits and conscripts, 112 
malingering, detection of, 171 
manifestations frequently described 

as shell shock, 30 
organic symptoms, 168, 169, 171 
physiological origin of, 133 
psycho galvanic reaction compared 

with that of neurasthenia, 291 
reflex disorders distinguished from, 

132 
reflex reaction in relation to, .1.82 
sensory disturbances in, 170, 171 
treatment of, 270 
tremor of, 161 
Hysterical anuria, 188 
Hysterical hemiplegia, see Hemi- 
plegia. 
Hysterical immobiUty, vaso -motor, 
thermal and secretory disturb- 
ances due to, 134, 135 
Hysterical manifestations, of irritant 

gases, 259 
Hysterical monoplegias and para- 
plegia, 143-50 
Hysterical mutism, Bastian's descrip- 
tion of, 101 
nature of the condition, 102, 103 
peculiarities of, 101 
Hysterical paralyses and contrac- 
tures, 132-8, 139-43 
Hysterical sensory conditions, treat- 
ment of, 281 
Hysterical speech defects, 94 
cases illustrating, 95-8 
grades resulting from emotional 

shock, 105 
observations on, 99 
treatment, 107 
See also Aphonii. 
Hysterics, examination of, 179-82 
estimation of genuineness of pain 

of, 179-81, 182 
removal of sensory symptoms in, 182 



338 



INDEX 



Hystero-epilepsy, and epilepsy, dif- 
ferential diagnosis of, 210, 213 

case illustrating differential diag- 
nosis, 213 

characteristics and symptoms of, 
211 

military service in relation to, 211 

Illuminating gas, 231 

suicide by, case illustrating symp- 
toms, 233 
Incongruous associations, of dreams, 
128 
cases illustrating, 128, 129 
Indecision, due to shell shock, 86 
Infantile demeanour, 81, 82 
Injuries, diagnosis of contractures 
and paralysis of limbs following, 
176 
examination of, 177 
psychopathic sensory disturbances 
following, 178, 179, 180, 182 
Insane, general paralysis of the, 
causation and characteristics, 
215 
Insanity, a predisposing factor of 
shell shock, 109, 110 
alcoholic, 227 
chronic delusional, characteristics 

and frequency of, 214 
disposal of cases of, 214 
malingering in relation to, 219 
periodic, causation and character- 
istics, 213 
Insomnia, characteristics and effects, 
191 
frequency in series of cases, 110 
light hypnosis for, 276 
subjective symptom of neuras- 
thenia, 191 
treatment of, 269 
Internal capsule, hsemorrhage into, 

40 
Intestinal symptoms of neurasthenia, 

195 
Intonation, and mechanism of speech, 

105 
Investigation, of motor function, 306 

of sensibility, 307 
Irresolution, due to shell shock, 86 
Irritable heart, 192 
Irritant gases, neurasthenia following 
exposure to attacks by, 260 
effects of, 259 

neurasthenic hysterical manifesta- 
tions of, 259, 260 

Jacksonian epilepsy, 209 



Joint movements, how tested, 177, 

306 
limitation of, causes, 305 
Joints, sense of position of, how 

tested, 309 

Kant, on the recollection of dreams, 

122 
Kinaesthetic disturbances, 133 
Kinaesthetic sense, loss of, 182 
Knee jerk, how obtained, 316 
Korsakoff psychosis, 228 

Labyrinthine excitation, method of 

testing, 77 
Language, primitive and articulate, 

105 
Laryngitis, due to mustard gas, 259 
following aphonia and mutism, 101 
inhalation for, 259 
Lassitude, 180 
Legs, exercises for, 281 

h3^sterical hemiplegia and contrac- 
ture of, 142 
loss of power in, in case of shell 

shock, 95 
motor points of {illiist.), 320-21 
peripheral sensory distribution of 

{illusL), 312, 313 
tendon reflexes of, how obtained, 
316 
Leri, on production of true commo- 
tion, 67 
Lewis, on syncopal attacks, 193 
Locus minoris resistentiac, 93, 107 
Lucretius, on dreams, 114, 115, 126 
Lungs, action of chlorine and phos- 
gene gas on, 248 
haemorrnage into, from aerial com-, 
pression, 38 

McCuRDY, on the anxiety neuroses of 

soldiers, 116 
Macropsy, 188 
Main accoucheur, 153 

case resembling (illusl.), 265 
case of (illusL), 266 
Main en ben tier, 153 
Main en griffe, simulating ulnar 

paralysis, 154 
Malingering, behaviour of patient 
during examination, 218 
cases illustrating, 221 
diagnosis of, 217-21 
estimation of genuineness of pain 

during, 179-81, 182 
evidence of deceit and cunning in, 
218 



INDEX 



339 



Malingering, examination for, 218, 
220, 221 
examination during, 179-82, 183 
in relation to tremors, 162 
reflex reaction in relation to, 182 
Maniacal excitement, 38, 45 
hypnotics in, 269 
paroxysmal attacks following shell 

shock, case illustrating, 124 
warm .bath useful in cases of, 269 
Manic depressive insanity, 213 

causation and characteristics, 213 
Masked epilepsy, characteristics, 212 
Mastication, loss of power of, in case 

of shell shock, 95 
Masturbation and neurasthenia, 196 
Mechanical appliances in treatment, 
gymnastic exercises contrasted 
with, 295 
Median nerve injury, condition of 
hand {illust.), 265 
paralysis (illust.), 194 
Medical Boards, orders in relation to 
neurasthenia, shell shock, and 
functional disorders, 260-2 
Medulla, haemorrhage into, 39 
Memory, and recollection, 86 
cause of loss of; 14 
definition of, 86 
impaired case illustrating, 86 

frequency in series of cases, 110 
lapses of, epilepsy in relation to, 

211, 212-13 
musical, cases illustrating, 91, 92, 
94 
observations on, 93 
test of, in officers suffering with 

neurasthenia, 292 
See also Amnesia. 
Mental attention, sustained, cerebral 

commotion in relation to, 86 
Mental cases, disposal of, 214 
Mental concentration, impaired, fre- 
quency in series of cases, 110 
Mental conflict, in relation to war 

psycho-neuroses, 138 
Mental confusion, hallucinatory, 203 
and hebetude, 80 
use of the term, 110 
with hallucinatory delirium, 70 
Mental defectives, characteristics and 

frequency of, 207 
Mental depression, as phenomenon of 

shock, 78 
Mental disorders, characterised by 
confusion, 204 
psychopathogenetic gauses of, 20/) 
soldiers developing, 108, 109 



Mental diversion of the patient, as 

aid to treatment, 297 
Mental examination of the patient, 

267 
Mental hygiene, in later stages of 

treatment, 270-2 
Mental instabihty, chronic alcoholism 

in relation to, 226 
periodic attacks of, 212 
Mental phenomena of shock, 36, 78 

case illustrating, 78 
Mental stability, grades of, in recruits, 

201 
Mental state, of neurasthenics, 196 

of psychasthenics, 206 
Mentality, functional motor disorders 

in relation to, 133 
Methsemoglobin, conversion of hsemo- 

globin into, by nitrous fumes, 241 
Micropsy, 188 
Migraine, see Headache. 
Miliary aneurysms (illust.), 243 
Miliary haemorrhages, in cases of shell 

concussion and gas poisoning, 236 
Military service, examination for, 111, 

112 
Mind and music, 93 
Mindless expression, following shell 

shock, case illustrating, 82 
Miner's nystagmus, diagnosed as 

disseminated sclerosis, 174 
Mines, dangers of carbon monoxide 

gas in, 249 
detection of gas in, 257 
prevention of gas poisoning and 

accidents in, 257 
Mining operations, nature of soil in 

relation to, 251 
Monakow, on causation of shock, 

17 
Monoplegia, brachial, characteristics 

and symptoms, 143 
crural, types and characteristics, 148 
Motor aphasia, hysterical mutism as 

an instance of, 103 
Motor disabilities, 155—8 
psychogenic, 131 

treatment by contra-suggestion, 158 
Motor function, investigation of, 307 
Motor points, electrical stimulation 

of, 318 
of arm and leg (illust.), 320-2 
of face and neck (illust.), 319 
Movement, disability of, 305 
Movements, active and passive, in 

treatment, 277 
of joints following wounds, how 

tested, 177 



340 



INDEX 



Movements, sense of, how tested, 309 

Mucous colitis, in neurasthenia, 195 

Muscles, contractibility of, how testetl, 

317 

degeneration of, indications of, 323 

diffuse amyotrophy in hysterical 

hemiplegias, 142, 143 
electrical stimulation of, 286, 318 
electrical treatment of, 278 
examination of, 306 
motor points of (illust.), 319-22 
of the spinal segments (table), 176 
of the trunk, contracture of, 150-2 
l)aralysis and atrophy following 

nerve injuries, 178 
])aralysis of, movements in treat- 
ment, 277 
paralysis or contracture of, 155 
reaction of, how tested, 178, 317, 

323 
treatment of, 274 
Muscular atrophy, 133 
how estimated, 306 
Muscular hypotonicity, diagnosis of 

organic hemiplegia by, 169 
Muscular tremors, 158-62, 191 
Muscular weakness, of neurasthenia. 
191 
characteristics, 191 
Music and singing, useful in after- 
treatment, 297 
Musical memory, in relation to shell 
shock, cases illustrating, 91, 92, 
94 
observations on, 98 
Mustard gas, aphonia and mutism 
from effects of, 101 
characteristics and effects of, 259 
neurasthenia following attacks by, 
260 
Mutes, expression of thoughts in 

writing, 104, 105 
Mutism, and aphonia, distinction 
between, 102 
atmosphere of cure in, 199 
blindness and deafness associated 

with recurring attacks of, 102 
cause of, 30 

emotional shock causing, 105 
following shell shock, 80', 185, 186 
frequency of, 94 
galvano-psychotherapy of, 101 
hysterical, cases illustrating, 95-8 
causation, 103, 104 
characteristics and nature of, 101, 

102, 103 
treatment, 107 
observations on causation, 99 



Mutism, pathogenesis of, 102 
phonation in relation to, 105 
recovery from, causes, 100 
shell shock and, case3 illustrating, 

95-8 
stammering and stuttering follow- 
ing, 101 
treatment of, 282 
See also Speech. 

Neck, exercises for, 280 
functional paralysis or contracture 

of, 152, 155 
hyperaesthesia of, 190 
motor points of {illust.), 319 
Nerve cells, changes in, 52, 53, 64, 65 
changes due to injurj', 10, 11 
changes in shell shock, 19, 42-6 
changes in spinal concussion, 57- 

60 
characteristics and functions, 5, 6 
condition following electric shock 

{illwst), 9 
condition immediately after Heath, 

11 
condition of, how ascertained, 10 
destruction of, 57 
energy substance of, how estimattxl, 

11 
microscopical examination of, 11 
staining of, 10, 13 
substance of, 11 
Nerve centres, exhaustion of, wound 

shock in relation to, 21 
Nerve deafness, from high explosives, 

74, 75 
Nerve injuries, electrical testing of 
muscles following, 178 
psychopathic sensory disturbances 

following, 179, 180 
resulting paralysis and deformity 
following, 178 
Nerve tonics, 270 

in treatment, 270 
Nerves, of the spinal segments (table), 
176 
peripheral distribution {illust.), 

310-14 
reactions of, how tested, 317-24 
Nervous cas&s, clinical examinations 

of, 324 
Nervous debiUty, 131 
Nervous disorders, soldiers develop- 
ing, 108, 109, 110 
Nervous exhaustion, classification of 

symptoms of, 201, 203 
Nervous predisposition to shock, 
analysis of series of cases, 108-10 



INDEX 



341 



Nervous system, action of alcohol on, 
224 

affections without visible external 
injury, 1 

anatomical changes in shell shock, 
49-61 

arrangement and structure of, 3, 
6-7 

concussion due to high explosives, 
25, 27 

diseases simulating neurasthenia, 
197 

dynamic conditions of, survey of, 
3 

effects of carbon monoxide poison- 
ing on, 255, 256 

effects of high explosives on, 1, 10, 
24-9 

evidence of organic disease of, 315 

haemorrhage into, cases of, 36 

histological changes due to shock, 
38-45 

histological changes in, case illus- 
trating, 51 

influence of carbon monoxide gas 
on, 231 

injuries from projectiles, 24 

injury without visible signs, 31, 36 

latent syphilis of, 215 

organic symptoms, without injury, 
69, 70 

shock to, see Shell shock. 

syphiUtic disease of, pupil pheno- 
mena, 174 
Nervous temperaments, and shell 

shock, 107 
Nervousness, a predisposing factor 

of shell shock, 109 
Neural exhaustion, 131 

cause of, 19 

causing shock, 19, 20 

continued emotivity and preoccu- 
pation causing, 131 

tremor a sign of, 161 
Neuralgic pains, relief of, 270 
Neurasthenia, acquired condition of, 
189 

acro-cyanosis of, 194 
(illusL), 194, 195 

and acquired emotivity, case illus- 
trating, 34 

and active service, 260-2 

and emotivity, frequent association 
of, 202 

and shell shock, 30, 35 

ataxia in cases of, 155, 156 

cardio-vascular symptoms of, 192-4 

cause of, 112 



Neurasthenia, class of patient acquir- 

ing, 131 
comparative study of personal 

history of series of cases of, 109 
Dejerine's definition of, 131 
diagnosis of, 197, 198 

differential, 198 
duration of, 199 
examination in, 198 
failure of accommodation and 

asthenopia in, 188 
following exposure to gas attacks, 

260 
following shell shock, causation, 16 
gastro-intestinal symptoms, 195 
genital functions in relation to, 113 
genito-urinary symptoms, 196 
headache of, 189 
hysterical symptoms, removal by 

contra-suggestion, 199 
in recruits and conscripts, 112 
insomnia of, 191 
memory and responsibility test in 

officers suffering with, 292 
mental state of, 196 
muscular weakness of, 191 
nature of the condition, 131 
nervous diseases simulating, 197 
non-hysteric neuropathic symptoms 

in, 130 
of soldiers, 116 

dreams in relation to, 119 
organic disease in relation to, 197 
psycho-galvanic method of deter- 
mining state of emotivity in, 290 
psycho-galvanic reaction compared 

with that of hysteria, 291 
psychology of soldiers' dreams in 

relation to, 114 
pupil phenomena of, 198 
respiratory difficulties simulating 

asthma in, 193 
secretory symptoms of, 195 
shell-shock type, hyperthyroidism 
with, 161 

symptoms, 35 
signs and symptoms of, 113, 188-99 
soldiers acquiring condition of, 107 
spinal hypersesthesia and rachialgia 

of, 190 
treatment of, 268-70 

by psycho-analysis, 288 
tremor of, characteristics, 161 
vaso-motor disturbances of, 194 
vertigo of, 191 

visceral-vascular symptoms of, 192 
visual and auditory sensory dis- 
turbances of, 184^7 



342 



INDEX 



Neurasthenic manifestations of irri- 
tant gases, 259 
Neuritis, peripheral, and hysterical 
paralysis, differential diagnosis, 
170 
Neuro-bions, 15 
Neurologists, French and German, on 

shell shock by windage, 67-70 
Neuro-muscular system, electrical ex- 
amination of, 317 
Neurons, action and function of, 10 
and oxygen, 15 

changes due to injury to, 10, 11 
characteristics and functions, 6, 7, 

13, 14 
degeneration of, 10 
dissociation of, 14 
exhaustion of kinetoplasm in, 20 
in relation to shell shock, 5-8 
living, in relation to shock, 8—15 
Neuropathic tendency, 110, 111 
in civil and army life compared, 
111 
Neuropathological theory of shock, 17 
Neuropathology of gas poisoning, 

240-8 
Neuropaths, in civil and army life. 111 

prevalence of. 111 
Nickel carbonyl poisoning, 232 
Nissl granules, 10, 11 
changes in, 42, 44, 45 
disappearance in shock, 19 
formation of, 11, 13 
Nocturnal emissions, 188 
Numbness, 309 

Nystagmus, disseminated sclerosis 
diagnosed as, 174 

OcciMTAL region, bullet wound of, 

effects of, 7 
Occupation, after-treatment by, 296-7 
Opium, in treatment, 269 
Oppenheim's sign, 170, 315 
Organic disease, accompanied by halo 
of functional disturbance, 172 
and functional differential diagnosis, 
172, 183, 197 
reflexes in dififerential diagnosis 
of, 315 
and neurasthenia, differential diag- 
nosis, 197 
diagnosis of, 172-5 
functional cases diagnosed as, 173 
indications of, 305 
Organic lesions, motor disturbances 

due to, 132 
Organic symptoms, of shell shock, 69, 
70 



Osmond, on eye lesions due to 

windage, 71, 72 
Oxidase granules, carbon monoxide in 

relation to, 250 
Oxides of nitrogen, generated by high- 

explosive shells-, 28 
Oxygen, and consciousness, 15 
in treatment of gas poisoning, 258 

Pain, estimation of genuineness of, 
179-81, 182 
" fixed idea " of, 178, 179, 180 
malingering in relation to, 219 
sensibility to, how tested, 308, 309 
Paraldehyde, in treatment, 269 
Paralysis, and contractures, 133—7 
following injuries, diagnosis of, 176 

examination of patient, 177 
functional, army discharge and 
pensioners in relation to, 263 
differential diagnosis from para- 
lysis due to organic disease, 
172-5, 183 
electrical treatment, 278 
following organic lesions, 132 
gymnasium in treatment of, 295 
of the hands, feet, shoulder, 

trunk, and neck, 152—4 
treatment, 277 
hysterical, cases illustrating, 143-50 
diagnosis of, 167-71 
differential diagnosis, 167, 172 
loss of bone sensibility and 

kinaesthetic sense in, 182 
treatment, 272-5 
organic, 132 

army discharge and pensioners 

in relation to, 265-6 
causes, 266 

in pensioners, 265, 266 
treatment, physio-psychotherapy, 
286 
Paralysis agitans, tremors resembling. 

161 
Paralytic astasia-abasia, character- 
istics, 156 
Paranoia, characteristics and fre- 
quency of, 214 
Paraplegia, functional, character- 
istics, 149 
functional, differential diagnosis, 
171 
faradic treatment, 286 
hysterical, case illustrating, 143-5 
spastic, characteristics, 150 
Passive movements, sense of, how 

tested, 308, 309 
Pathogenesis, of mutism, 103 



INDEX 



343 



Pathology, of shock, 16, 17 
Patient, examination of, 267, 305 
scheme of, 324 
his faith in treatment, 200, 268. 

275, 276, 277 
military history of, 303 
pre-war history of, 303 
Pensioners, chronic functional para- 
lyses and contractures in, 263-() 
Pensions, examination for, 303, 305 
functional disabilities frequently 

perpetuated by grant of, 277 
scheme of examination, 324 
Peripheral sensory distribution of 
lower Umb (illust), 312, 313, 314 
of upper limb {illust.), 310, 311 
Personal history, in series of cases of 

shell shock, 109, 110 
Persuasion, see Contra-suggestion. 
Pharyngitis, due to mustard gas, 259 

inhalation for, 259 
Pharynx, anaesthesia of, in mutism. 

i02 
Phobias, of psychasthenics, 207 
Phonation, absence of, causes, 282 
articulate speech impossible with- 
out, 105 
complete loss of power of, 105 
dissociation or inhibition of me- 
chanism of, 103, 104 
mechanism of, 106, 283 
weak power of, 105 
Phosgene, 260 
action of, 241 

symptoms of poisoning by, 240, 248 
Photophobia, 188 
Phthisis, and neurasthenia, differential 

diagnosis, 197 
Physical causes of shell shock, 2 
Physical shock, and emotional, 30 

characteristics, 16 
Physiological alphabet, in treatment 
of stammering and stuttering, 
285 
Physiopathic organic disorders, 137 
Physio -psychotherapy of analgesia, 
286 
of blindness and defects of vision, 

187 
of brachial monoplegia {illust.), 

147 
of functional disease in relation to 

organic, 173 
of functional hemiplegia {illust.), 

147 
of irritant gas cases, 259 
of mutism, 282 
of paralysis, 286 



Physio-psychotherapy, of paralyses 
and contractures, 147-50 
See also Treatment. 
Pia mater, function of, 237 
Pithiatism, 130 
Plantar extensor sign of Babinski, 

168, 171 
Plantar reflex, after epileptic fits, 210 
how examined, 315 
suppression of, by mahngerers, 183 
Platysma, sign of organic hemiplegia. 

169 
Plicature, 151 

Pneumonia, complicating gas poison- 
ing, 233, 234 
Pons, haemorrhages into white matter 

of, 41 
Potassium bromide, in treatment, 269 
Pressure, sensibihty to, how tested,308 
Primitive language, and articulate, 105 
Projectiles, destructive power of, 23 
forms of, 23 
See also Windage. 
Pronation sign of organic hemiplegia, 

170 
Pseudo-angina, in cardiac neuras- 
thenia, 193 
Pseudo-arthritis, 180 
Pseudo-coxalgia, 180 

case of malingering, 221 
Pseudo-spondyhtis, 152 
Psychasthenia, 206 
characteristics, 206 
treatment, 207 
Psychic shock, characteristics and 

causation, 2, 16, 18, 19 
Psycho-analysis, 117 

by word association, 287 
. treatment by, 287 
Psycho-galvanic method of investiga- 
tion, 289-92 
Psychogenic amnesia, characteristics 
and causes, 90 
cases illustrating, 89, 90 
Psychogenic factor, predominant 
causal agent in war psycho- 
neuroses, 5 
of shell shock, 35, 36 
Psychogenic motor disorders and 

disabilities, 131 
Psychological syncope, 120 
Psychology of the emotions, 18, 19 
Psycho neurasthenia, subjective and 

objective symptoms of, 201 
Psycho-neuroses, see War psycho- 
neuroses. 
Psychopathic basis, in war neuroses, 
108 



844 



INDEX 



Psychopathic sensory disturbances 

and disabilities, 178, 179 
Psychopathies, chronic states, 203 
Psychopaths, contractures and para- 
lyses in, 133 
mental conflict of, 138 
prevalence of. 111 
in civil and army life. 111 
Psycho-sensorial affections, 183 
Pulmonary apoplexy,f rom mndage, 70 
Pulse rate, in cardiac symptoms of 

neurasthenia, 192 
Punctiform haemorrhages, 249, 256 
anatomical relations of vessels 

favouring, 237 
cases illustrating, 246 
causes, 247, 248 
characteristics, 242 
due to carbon monoxide poisoning, 

229, 233 
hyaline thrombosis of vessel in 

centre of [illust.), 242 
in case of shell shock and burial, 

238, 239 
to what due, 234 
(iUxist), 232-5, 242-5 
Pupil phenomena, of tabes, 174 
of neurasthenia, 198 
of latent syphilis, 215, 216 
Purkinje cells, changes in, 42, 45 
exhaustion of kinetoplasm a causal 
factor in shock, 20 

Quaking, see Tremors. 

Quiet and rest, in treatment, 270 

Quinine, in treatment, 270 

Rachialoia, as symptom of neuras- 
thenia, 190 
Reaction of degeneration, how tested, 

324 
Reactions, muscular, how tested, 317. 

323 
Recognition, cause of loss of, 14 
Recollection, cause of loss of, 14 
imi>aired, due to shell shock, 86 
of dreams, ] 22 
Recreation, in later stages of treat- 
ment, 270, 271 
Recruits, and epilepsy, 209 
dementia prsecox in, 205 
examination of, 179-81 
feeblemindedness in, 207 
functional disorders of the heart in, 

192 
grades of mental stability in, 201 
latent syphiUs in, 215 
organic brain diseases in, 217 



Recruits, psycho-neuroses in, 112 
spinal neurasthenic symptoms of, 

191 
unfitness of, 113 
Re-education, by exercises, 279 
method of, 277-80 
of stammerers and stutterers, 284, 

285 
reinforced by electricity, 278 
Reflex, •' dodging," 163, 165 

" startled," 164 
Reflex paralysis and contractures, 

133-7 
Reflex reaction in relation to hysteria 

and malingering, 182 
Reflexes, examination of, 306 

importance in differential diagnosis 
of organic and functional disease, 
315 
in diagnosis of hysteria, 169-71 
Respiration, cerebro -spinal fluid in 
relation to, 3 
effect of shell shock on, 3, 4 
Respiratory difficulties, in cardiac 

neurasthenia, 193 
Responsibility, test of, in officers 

suffering with neurasthenia, 292 
Rest and quiet, in treatment, 270 
Retina, detachment due to windage,72 

lesions due to ^vindage, 72, 73 
Rivers, on the theory of Freud, 117 
Rum ration, value of, 222, 224 

Sarbo, on shell shock by windage, 69 
Scalp, hvperajsthesia of, 190 
Scars, of wounds, 265 
Sciatica, changes in, 219 
Secreto-motor reactions, the outcome 
of suppressed fear during the 
waking state, 121 

the outcome of terrifying dreams, 
122 
Secretory disturbances, cases illus- 
trating, 134-6 

cause of, 134, 135 

of neurasthenia, 195 
Sedative effects, of alcohol, 224 
Sedatives, in treatment, 270 
SensibiUty, bone, how tested, 309 

cutaneous, how t&sted, 307 

deep, how tested, 308 

investigation of, 307 

objective disturbances of, 307 

pressure, how tested, 308 

subjective disturbances of, 309 

tactile, how tested, 307 

to heat and cold, how tested, 308 

to pain, how tested, 308, 309 



INDEX 



345 



Sensory disturbances, due to gas 

poisoning, 256 
following injuries, 178, 179 
in hysteria, 170, 171 

treatment of, 281 
Sexual complexes, 118 
Sexual desire, loss of, 196 
Sexual functions, in relation to 

neurasthenia, 189 
Sexual neurasthenia, characteristics, 

196 
Shakespeare, on dreams, 115 
Shell concussion, and gas poisoning, 
miliary haemorrhages in, 236 

microscopic examination of brain 
in, 245-7 
Shell gas, causation of instantaneous 

death from, 25—9 
destructive power of, 23 
Shell shock, active service in relation 

to, 260-2 
alcohol in relation to, 222-8 
amnesia following, 82, 84, 89 

cause of, 14 

anterograde, 79 

retrograde, 14, 31, 79 
anatomical changes in, 47-61 
and burial, carbon monoxide poison- 
ing in, 238 
and contusion, fatal case of, 51 
appUcation of the term, 2 
astasia-abasia following, 156 
atmosphere of cure in, 275 
blindness and deaf-mutism follow- 
ing, cases illustrating, 183, 184, 

187 
blood pressure in relation to, 20, 21 
brain examination in cases of, 37, 

46, 48 
by windage, opinions of French and 

German neurologists on, 67 
causation, 1, 2 

physical and psychic, 2 

theories of, 16-22 
cell changes in, 19, 42-63 
cerebral anajmia in, 41 
cerebral haemorrhage in, 38-42, 46, 

50,52 
cerebro-spinal, fluid pressure in 

cases of, 268, 269 
commotional, see Commotional 

shock, 
consecutive mental phenomena of, 

36, 78 
cortical symptoms, 15, 16, 84 
deafness and deaf -mutism following, 

184, 186 
decline of symptoms, 35 



Shell shook, different forms of, 16 
dreams in relation to, 114-20 
ear lesions and, 74-6 
emotional, see Emotional shock, 
epilepsy arising from, 208 
eye lesions and, 71-3 
facial paralysis following, case 

illustrating, 140 
fatal initial stage of, cases illus- 
trating, 37, 46, 48 
gas poisoning in relation to, 228, 238 
general paralysis in relation to, 215, 

216 
Grave's disease in relation to, 22 
histological changes in, 38 -45 
hysteria and, 35 
hysterical manifestations frequently 

described as, 30 
malingering in relation to, 217-21 
maniacal excitement following, 124 
mechanism of production of, 3, 7, 13 
memory and recollection in relation 

to, 86 
mental confusion with hallucinatory 

delirium following, 79, 80 
mental hygiene in later stages of, 

270 
musical memory in relation to, 91-4 
nervous temperaments in relation 

to, 107 
neurasthenia and, 35 
neurasthenic condition following, 

16, 30, 198 
neuropathic tendency to, 110, 111 
neuro-pathological origin of, 17, 18 
neuron doctrine in relation to, 5-15 
personal history of series of cases, 

109, 110 
physical, 2, 16 

predisposing factors of, 107-10, 111 
primary, 17, 18 

psychic, characteristics and causa- 
tion, 2, 16, 18, 19 
psychogenic factor of, 35, 36 
rarely associated with external or 

somatic wounds, 110 
secondary, 17, 18 

speech defects in relation to, 94-105 
sphincter affections following, 188 
spinal commotion and, 63 
spinal concussion in, 54, 56 
sudden death following, 46 

without visible signs of injury, 
25-9, 48-50 
symptoms which are seldom absent 

in true cases of, 269 
syphilis in relation to, 215, 216 
treatment of, 268-70 



346 



INDEX 



Shell shock, tremors, tics and chorei- 
form movements due to, 158-66 
true, differential diagnosis, 31 
vascular changes in, 38, 45 
vascular origin of, 17, 18 
vision, defects of, following, 187 
voltaic vertigo and, 76 
without visible signs of injury, 1, 
25, 31, 36, 96 
Shells, nature and explosive force of, 
23, 24, 25 
See also High explosives. 
Shock, see Shell shock ; Wound shock ; 

Commotional shock, etc. 
Shoulder, dropping of, a common 
spasmodic tic, 165 
case illustrating, 165 
exercises for, 280 
functional paralysis or contracture 

of, 152, 155 
pseudo-arthritis of, 180 
Singing classes, useful in after treat- 
ment, 297 
Skin, action of mustard gas on, 259 

See also Cutaneous sensibility. 
Skull injuries, epilepsj" following, 209, 

210 
Soil, in relation to gas poisoning, 251 
Soldiers' dreams, see Dreams. 
Sound, mechanism of production of, 

103, 104, 284 
Spasmodic tics, characteristics, 163-5 

stereotypism of, 164, 165 
Spastic paraplegia, characteristics, 150 
Speech, infantile, following shell 
shock, case illustrating, 82 
mechanism of, 103, 105, 284 

diagram illustrating, 106 
recovery of, dreams in relation to, 
100 
observations on, 99 
sudden recovery of, cases illustrat- 
ing, 98 
Speech defects, 81 
frequency of, 94 
hysterical, 94 
mechanism of, 103 
treatment of, 283, 284 
See also Aphonia ; Mutism. 
Sphincter affections, following shell 

shock, 188 
Spinal commotion, case illustrating, 62 
microscopic examination of cord in, 

63 
without injury, 66 
Spinal concussion, anatomical changes 
in, 62, 63 
causing hsemfito-myelia, 174, 175 



Spinal concussion, cell changes in 
{illiist.), 58-60 
description of cord in, 56 
histological examination of cord, 67 
without evidetice of injury, 53, 62 
cases illustrating, 54, 55 
Spinal cord, anterior horn cell of 
(illust.), 11, 12 
bullet fracture of, case illustrating, 

174, 175 
functional curvature of, 150 
case illustrating, 151 
causation, 151 
gunshot wounds of, characterictics, 

174 
hystero-organic lesions, 171 
microscoj)ic examination of, 63 
organic and functional disease of, 
differential diagnosis, 174 
Spinal haemorrhages, 63. 64 

(illuM.), 64, 65' 
Spinal hyper.x'sthesia. as symptom of 

neurasthenia, 190 
Spinal rachialgia, nature of pain of, 180 
with curvature of functional origin, 
175 
Spinal segments, with their nerves and 

muscles (table), 176 
Stammering, following mutism, 101 
frequency of, 94, 95 
treatment of, 283 
Standing, loss of power of, 156 
Startled reflex, 164 
Staso-basophobia, 157 
Stereognostic perception, 309 
Stereotypism, of spasmodic move- 
ments, 164, 165 
Stevenson, Surg.-Gen., on sudden 
death due to explosive shells, 27 
Stokes-Adams' disease, cardiac symp- 
toms of neurasthenia in relation 
to, 193 
Stomach crises, of neurasthenia, 195 
Strychnine, in treatment, 270 
Stuttering, 94, 95 

following mutism, 101 
treatment of, 283 
Subjective disturbances of sensibility, 

309 
Suggestion, see Contra-suggestion. 
Suicidal tendencies, case illustrating, 
79 
shock in relation to, 78, 79 
.Miicide, by gas poisoning, 229, 233 
chronic alcoholism in relation to, 
- 226,227 
Syncope, characteristics of the attacks, 
193 



INDEX 



847 



Svncope, heart cases in relation to, 
193 
psychological, 120 
SyphiUs, latent, frequency of, 215 
in recruits, 215 • 
shell shock in relation to, 21(5 
test for, 215 
pupil phenomena of, 174 
Syphilophobia, 207 

Tabes, examination in, 174 

in recruits, 215, 216 
Tachycardia, in cases of shock, 122 
Tactile sensibility, 307 

how tested, 307 
Talipes equino- varus, 154 
{illusL), 148 
case illustrating treatment (illusL), 

272-3 
functional contracture with exten- 
sion and {illust.), 148 
physio-psychotherapy of, 148 
treatment of, 274 
Tendo Achillis jerk, how obtained, 31(3 
Tendon reflexes, how tested, 316 
Terrifying dreams, 79, 86, 95, 114, 118, 

119 
Terror, 82 

emotion of, with symptoms of 

actuaj commotion, 36 
nature of, 120, 121 
Tetanus, late, and reflex contracture, 

172 
Thermal disturbances, cases illustrat- 
ing, 134-6 
causation, 134, 135 
Thermoansesthesia, 308 
Thigh muscles, motor points of 

(illusL), 320 
" Tickhng " reflexes, 182 
Tics, 158 

causation, 159 

forms and characteristics, 163 
spasmodic, stereotypism of, 165 
typical example of, 165 
Tonic spasms, tics due to, 163 
TorticolUs, facial spasm and (illusL), 

164 
Tracheitis, due to mustard gas, 259 
Treatment, atmosphere of cure in, 
199, 271, 275 
by counter-suggestion, 276 
by psycjio-analysis, 287 
general, 267 
gymnasium in, after functional 

paralyses and contractures, 295 
hypnotism in, 276 
mental hygiene in, 270-2 



Treatment, military discipline during, 
276, 277 
occupation following, 296, 297 
of analgesia, 286 

of contractures and deformity, 274 
of hypothermia, 274 
of hysterical paralyses, 272-5 
of hysterical sensory conditions, 281 
of mutism, 282 
of paralysis, 286 
of shell shock and neurasthenia, 

268-70 
of stammering and stuttering, 283 
re-education in, 277-80 
types of cases requiring, 268 
See also Physio-psychotherapy. 
Tremors, 158 

characteristics and production of, 

159 
classification of, 159, 160 
conditions of the patient, 160 
emotion of fear in production of, 159 
fine vibratile, 161, 191 
in severe cases of shell shock, 160 
malingering in relation to, 162 
of disseminated sclerosis, 161 
of neurasthenia, 161, 191 
resembling paralysis agitans, 161 
resembling tremors of definite dis- 
eases, 160 
simulation bv hysterics, 162 
test for, 162 ' 
treatment, 162 
voluntary, test of, 162 
Triceps reflex, how obtained, 316 
Trinitrotoluene, carbon monoxide poi- 
soning from, 29 
explosive force of, 23 
Trional, in treatment, 269 
Tuberculosis, as a predisposing factor 

of shell shock, 109 
Twins, similarity in vocal intonation 

of, 105 
Tympanic membrane, effects of high 
explosives on, 74 
perforation of, treatment, 75 
rupture from high explosives, char- 
acteristics, 74-5 

Ulnae paralysis, following shrapnel 
wound (illusL), 177 
functional main en griffe simulat- 
ing, 154 
Unconscious, Freud's theory of the, 287 

dreams in relation to the, 118 
Unconsciousness, amnesia confounded 
with, 84 
mechanism of production, 14 



348 



INDEX 



Urinary symptoms of neurasthenia, 

196 
Urine, incontinence in hysteria, 188 
retention of, following shock, 188 

Valerian, in treatment, 270 
Valvular disease of the heart, 192 
Vascular symptoms, of neurasthenia. 
192 

of shell shock, 38, 45 
Vascular theory of shock, 17, 18 
Vasomotor disturbances, 132 

cases illustrating, 134-6 

causation, 134, 135 

of neurasthenia, 194 

outcome of suppressed fear during 
the waking state, 121 

outcome of terrifying dreams, 122 
Veins, paralysis of, low blood -pressure 

in relation to, 21 
Vent du projectile, see Windage. 
Veraguth's galvano-psychic method 

of inv&stigation, 289-90 
Vertigo, 81 

cause and characteristics, 191, 192 

due to high explosives, 74 

frequency in series of cases, 1 10 

of neurasthenia, 191 

See also Voltaic vertigo. 
Vin gai, 226 
Vin triste, 226 

Visceral-vascular symptoms, of neu- 
rasthenia, 192 
Vision,def ects f oUowingshell shock, 1 87 

narrow and spiral fields of, 73 

See also Blindness. 
Visual concussion, 73 
Vocal cords, function and action of, 

284 
Vocal intonation, 105 
Vocal mechanism, restoration of func- 
tion of, 99, 100 

See also Speech. 
Voltaic vertigo, diagnosis, 76 

comparative results of trephined 
and commotional cases, 77 

due to explosives, 76 
Vomiting, in neurasthenia, 196 

Waking state, 122 

hallucinations and illusions during, 
123 

secreto-motor and vaso-motor re- 
actions the outcome of suppressed 
fear during the, 121 



Walking, loss of power of, 156 
War psycho-neuroses, and ci\'il, com- 
pared, 200, 201 
causal agent in, 5, 107 
characteristics and nature of, 130, 

131, 200, 201 
classification of symptoms, 201-3 
comparative study of personal his- 
tory in series of cases, 109, 1 10 
conclusions from study of series of 

cases, 110 
course and progress of, 199 
emotive, symptoms, 202 
general treatment, 267 
in recruits and conscripts, 112 
influence of alcohol in production 

of, 222 
mental conflict in relation to, 138 
predisposing factors of, 107 
psychoi)athic basis of, 108 
See also Shell shock. 
Warm bath, in treatment, 269 
W^eariness, 189 
Will-power, loss of, in neurasthenia, 

196 
Windage (vent du projectile), effects 
upon the ear, 71, 71-0 
effects upon the eye, 71 
experiments on animals, 70 
opinions of French and German 
neurologists regarding shell shock 
by, 67-71 
Workshops, in after treatment, 296 
\\'ound shock, cause and nature of, 
20,21 
fall of blood pressure in fatal cases 

of, 20 
intravenous gum solution for, 22 
low blood pressure in, 20 
Wounded, comparative study of per- 
sonal history of series of cases of, 
109 
conclusions from study of series of 
cases of, 110 
Wounds, diagnosis of contractures and 
paralysis following, 176 
examination of, 177 
external or somatic, war neurosis 
rarely associated with, 110 
Wrist-tap contraction, how obtained, 

317 
Wyllie's physiological alphabet, 285 

X-rays in examin-ition of wounds, 
177 



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